This inspection was carried out on 2nd September 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.
CARE HOMES FOR OLDER PEOPLE
Lickey Hills Nursing Home (Cofton Unit) Warren Lane Rednal, Birmingham West Midlands B45 8ER Lead Inspector
Chrissy Presley Unannounced 2 September 2005 12:00md 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. Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Lickey Hills Nursing Home (Cofton Unit) Address Warren Lane, Rednal, Birmingham, West Midlands B45 8ER 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) 0120 445 5532 0121 445 5532 Parkcare Homes (No 2) Limited Mrs Christine Alexander Care Home with Nursing 97 Category(ies) of DE(E) Dementia over 65 (47) registration, with number LD Learning disability (4) of places OP Old age (97) PD Physical disability (3) PD(E) Physical disability 0ver 65 (97) Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Category LD is restricted to persons over 50 years of age. Date of last inspection 10 February 2005 Brief Description of the Service: Lickey Hills Nursing Home is situated in a picturesque area of Barnt Green close to the Lickey Hills’ visitor‘s centre. It comprises of two units, one catering for the elderly physically frail (Cofton Unit) and the other for the elderly mentally frail Rednal Unit). Both units are on two floors and all rooms, single and shared have en-suite facilities. Access to the first floor areas is gained through the use of stairways or passenger lifts. Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection of two hours duration concentrated on recruitment procedures, training records, staff complement and induction and foundation programmes for staff. Time was spent over the lunchtime period in Cofton Unit. What the service does well: What has improved since the last inspection? The refurbishment programme continues. Since the last inspection the home had employed four more trained staff. Arrangements at senior staff level on Rednal Unit were in progress and changes were being implemented. The Responsible Individual was working with the homes registered manager and her senior to ensure staff had adequate English language skills and extra help and support was given to these staff. Arrangements over the lunchtime period in Rednal Unit had been addressed and more staff were available during this busy period. Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.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. Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.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 Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.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) None of the standards in this section of the report were inspected during this visit. EVIDENCE: Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.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) None of the standards in this section of the report were inspected during this visit. EVIDENCE: Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 10 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) None of the standards in this section of the report were inspected during this visit. EVIDENCE: Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 11 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) None of the standards in this section of the report were inspected during this visit. EVIDENCE: Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 12 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) None of the standards in this section of the report were inspected during this visit. EVIDENCE: Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 13 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) 27,28,29 &30 Recruitment procedures are robust and ensure residents are safeguarded; training records in relation to mandatory training did not provide assurance that all staff have the necessary knowledge and skills to ensure the ongoing safety of residents in their care. EVIDENCE: Recruitment procedures were robust in the home, four staff files were checked and were found to be in order. All staff had a POVA first check before commencing work in the home and a criminal record check at enhanced level. There continued to be a number of staff vacancies in the home and a high usage of agency staff to cover shifts. Some overseas staff working in the home did not have a good command of the English Language and ways of improving this was being sought. The number of staff available in Rednal unit to assist residents over the lunchtime period had improved and from observation during lunch on Cofton unit there appeared to be enough staff to meet the needs of the residents. The home employed a training officer who worked two days per week; the senior clinical sister working in the home said they needed more support in order to ensure training was kept up to date. With a high turn over of staff induction and foundation training records had lapsed.
Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 14 The training matrix was not up to date and it was difficult to evidence all staff had received training in moving and handling and fire. This was of particular relevance as during the last inspection the inspectors had witnessed a number of residents being moved inappropriately. Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 15 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) None of the standards in this section of the report were inspected during this visit. EVIDENCE: Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 16 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 17 Are there any outstanding requirements from the last inspection? yes refer to last report 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 OP27 Regulation 18 Requirement Continued efforts must be made to recruit adequate numbers of suitably qualified staff to work in the home Traiinng records open to inspection must be updated There must be evidence that staff have completed an induction programme relevant to the post they hold in the home. There must be evidence that staff have completed a foundation programme relevant to the post they hold in the home Induction and foundation records must evidence these programmes have been completed Timescale for action Immediate 2. 3. OP30 OP30 18 12, 18 Immediate Immediate and ongoing Immediate and ongoing Immediate and ongoing 4. OP30 12, 18 5. OP30 18 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 OP8 Good Practice Recommendations it is recommended photographs of pressure areas and wounds are photographed with residents consent
E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 18 Lickey Hills Nursing Home (Cofton Unit) 2. OP30 The company should consider employing a training officer full time Lickey Hills Nursing Home (Cofton Unit) E52 S4122 Lickey Hills NH (Cofton Unit) V247668 020905.doc Version 1.40 Page 19 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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