CARE HOMES FOR OLDER PEOPLE
Manor House 1 Amblecote Avenue Kingstanding Birmingham B44 9AL Lead Inspector
Jill Brown Unannounced 28th July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manor House E54 S16775 ManorHse V242467 280705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Manor House Address 1 Amblecote Avenue Kingstanding Birmingham B44 9AL 0121 360 0680 0121 325 1511 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) Servite Houses Ms Sandra Taylor Care Home 35 Category(ies) of Care Home registration, with number of places Manor House E54 S16775 ManorHse V242467 280705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 17/01/05 Brief Description of the Service: The Manor House is situated in a quiet residential area of Kingstanding in a modern purpose built building. It has access to buses within about 5-10 minutes walking distance and is accessible to the shopping area of Kingstanding itself. Servite Housing owns the home: one of two such homes in the city of Birmingham. It has accommodation for 35 older people set out in 35 single bed sitting rooms. These rooms also have a kitchenette area and en-suite facilities. The home has communal areas of a lounge /dining room, a separate conservatory, and a hair dressing room. The home has assisted bathing facilities on both of its two floors. The upper floor can be accessed by a passenger lift if needed. There is a level access entry to the front of the building and to the rear garden area. There are parking spaces available at the front of the building. Manor House E54 S16775 ManorHse V242467 280705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place for approximately six hours on a day in July. Ten residents and the relatives of two residents were spoken to. Care plans for three residents were looked at in detail and another checked in some areas. Three staff files were sampled and a duty rota for a month was taken away for checking. Records of routine maintenance and inspection were looked at for fire, the passenger lift and for gas and electrical supplies. What the service does well:
The home provides good information for residents and relatives when they apply for a place at the home. They undertake their own assessment as well being informed by any assessment that may have been done by a social care or health professional. In this way the home ensures that the number of placements that are unsuccessful are kept to a minimum. A relative said that the home was very welcoming to their relative when she first came into the home. The home gives good personal care with residents that need assistance. Residents appeared well cared for and personal hygiene and laundry needs were met. Residents were enabled to have services from doctors district nurses chiropodists and so on when needed. Residents said that they enjoyed the activities the home provided a number commenting on the singsongs and bingo evening being good. Another resident said that she preferred to stay in her flat and the staff did not make her join in. Residents said the breakfasts were good. The inspector saw of a range of breakfasts being prepared, a number of residents opting for a full cooked breakfast others, a bacon sandwich or cereal. A resident said that she liked how the home always had fresh fruit available and that teapots were put on the table so they could help themselves to the amount of tea they wanted. The relatives spoken to said the home was always appeared clean and fresh and this was true on the day of the inspection. The home had appropriate management and the records held by the home were maintained in orderly fashion.
Manor House E54 S16775 ManorHse V242467 280705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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.
Manor House E54 S16775 ManorHse V242467 280705 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 Manor House E54 S16775 ManorHse V242467 280705 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) 1, 3, 5 The home provides adequate information about the home to residents and their families. Assessments are undertaken and where necessary include assessments from Social Care and Health professionals and this enables placements of residents to succeed. EVIDENCE: The home has a statement of purpose and a service user guide available for residents and their families. A relative spoken to stated that the home gave them information about the home prior to admission. The home had made all arrangements to ensure that their relative felt welcome including some flowers in her room on arrival. Residents apply to be admitted to the home. When there is a vacancy the home undertakes an assessment of resident’s needs as well as any that may be provided by Social Care and Health departments. These assessments meet the standard. There were individual risk assessments on residents’ files. The risk assessments covered issues identified in the assessment such as placement of the cord for the call alarm during the night and risk of falls.
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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 Care plans and monitoring of health care needs were variable and this did not ensure the continued well-being of residents. Residents’ personal hygiene needs were met. EVIDENCE: Care plans were variable with a number becoming more individualised. Where agreements had been made with the resident about their care this was recorded in the care plan summary. Others still did not give clear instructions to staff in an easy format. Residents appeared well cared for with their personal hygiene needs met. Clothes were well laundered and ironed. On one file it was recorded that a resident was falling a risk assessment was in place but analysis of falls was not seen on this occasion. Residents’ weights were recorded routinely where possible but the home could not show how unplanned weight loss over a long period was responded to. It was clear on records that residents had regular contact with their GP and other health associated professionals such as dentists and chiropodists where necessary. None of the residents files looked at showed that residents had pressure areas or sores.
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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) 12, 13 & 15 Arrangements for activities, visiting and meals were good and these enhance the quality of life for residents. EVIDENCE: One resident said that they had activities and that he liked to join in. He said that there was sing songs, housey-housey and tombolas. Several residents spoke off the bingo and how they were assisted to play this. All residents spoken to were happy with the activities provided. Residents’ files had recorded the activities that residents had undertaken on any day and this was an improvement. One resident said that she didn’t particularly want to join in activities and wasn’t made to. The inspector noted that residents went out of the home with relatives and one resident said that he could go out alone but he had to tell the office so they don’t worry about him. Residents were able to see visitors privately in their flats and there were no undue restrictions for visiting times. The inspector sat with residents at breakfast. Residents that wished to have breakfast downstairs arrived at differing times. Residents spoken to were enjoying a cooked breakfast. One resident said she had decided on a bacon sandwich and this had been accommodated, another resident said that he always had a choice of breakfast. The breakfasts appeared well cooked. One resident said that she liked that the home made sure there were teapots on the table so you could serve yourself and there was always fruit available.
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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) EVIDENCE: These standards were not inspected on this occasion however the inspector noted that the Commission had received no complaints about the home since the last inspection. Manor House E54 S16775 ManorHse V242467 280705 Stage 4.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) 26 The home was clean and fresh and this makes a comfortable environment for residents. EVIDENCE: The home appeared clean and fresh on arrival two relatives said that this was the usual situation when they visited the home. A tour of the building was not conducted on this occasion. The home had improved the lighting in the conservatory since the last inspection. The inspector was advised that a replacement carpet for the dining and lounge area was to be fitted shortly and there was evidence of some redecoration of this area. Manor House E54 S16775 ManorHse V242467 280705 Stage 4.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, 29 & 30 The numbers, timing and consistency of staff was not always adequate and this potentially could put residents at risk. Staff were recruited well with good checks being undertaken before employment and this protects residents. EVIDENCE: The home had a manager on duty during waking hours and had on call arrangements at night. The home had separate housekeeping and catering staff. The home had been using agency and relief care staff over the last month and had vacancies for care staff. The home had residents that require substantial amounts of assistance on the morning and the staffing levels were variable. The home needs to consider new admissions against their current staffing levels. The current staffing levels must be reviewed in line with the dependency of the residents and the timings of the assistance each needs. The staff files looked at had improved since the last inspection. Files were found to have the appropriate checks and references prior to employment. Due to new guidance copies of the CRB declarations for new staff are to be placed be on staff files until a Commission’s inspector sees them. Some staff training qualifications were seen on files. These were not checked against the standard on this occasion. The home sent details of individual course attendees to the inspector prior to the report being written. It was clear that staff received training but analysis of the staff team’s performance could not be undertaken and this was not included with the information sent. A number of the staff files did not have evidence of the staff’s induction to the home.
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The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36, 37 & 38 Arrangements for the management, supervision of staff and the keeping of records were good and this ensures good communication between residents staff and management. Some Health and safety requirements in respect of fire, lift inspection, and hard wiring safety could not be found and this could be a potential risk to residents. EVIDENCE: The registered provider had requested that the homes manager undertake a new role for their organisation for a period of time. In her absence the home’s deputy had taken over the role of manager. She had successfully undertaken the required registered manager process with the Commission and was undertaking the required registered manager training. Manor House E54 S16775 ManorHse V242467 280705 Stage 4.doc Version 1.40 Page 15 The staff files showed that staff had regular routine supervision and that this covered areas required by the standard. The records in the home were kept in an ordered and an accessible fashion. The home had appropriate gas certificate and public liability insurance. The insurers lift inspection report and the five-year wiring certificate were not available for inspection. The home had a recent inspection from the West Midlands Fire Service there were a number of requirements not all of these had been met. One resident’s smoking risk assessment had not been placed on the home’s fire risk assessment. The home’s fire risk assessment had not been reviewed in the last 16 months. The home had undertaken drills and routine tests the home should keep evidence of fire exits being clear and door closures being effective. Manor House E54 S16775 ManorHse V242467 280705 Stage 4.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 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3
COMPLAINTS AND PROTECTION x 2 x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 2 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 3 x x x x 3 3 2 Manor House E54 S16775 ManorHse V242467 280705 Stage 4.doc Version 1.40 Page 17 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard op7 Regulation 15(1) Requirement The home must ensure that care plans show how needs are to be met and as far as practicable take into account service users wishes and feelings. (This remains outstanding since 28/02/05) Following a service user’s fall the moving and handling assessment and risk assessment must be reviewed to ensure its continued appropriateness. (this requirement was not assessed on this occasion and was brought forward.) The carpets in the dining room and the conservatory must be deep cleaned, repaired or replaced. (this requirement remained outstanding since 31/05/05) The home must always be adequately staffed to meet the needs and dependency of the residents. The home must provide to the Commission the dependency and profiled needs of the residents and advise the Commission how these will be met. All new staff must have evidence Timescale for action 31/12/05 2. op8 13(5) & 13(4)(c) 30/09/05 3. op19 23(2)(d) 31/03/06 4. op27 18(1)(a) 30/09/05 31/12/05 5. op29 18(1)(a) 31/08/05
Page 18 Manor House E54 S16775 ManorHse V242467 280705 Stage 4.doc Version 1.40 (c) 6. op30 7. op38 of an induction process in their first days of work. 18(1)(c) & The home must ensure that all 19 staff complete the required schedule training in line with the National 2(4) Training Organisations guidelines. Copies of staff qualifications must be retained on a staff file. ( these requirements remain outstanding since 31/03/05) 23(2)(b) A copy of the insurers report for (c) the inspection for the passenger lift must be sent to the Commission and a copy retained in future at the home for inspection. 31/10/05 30/08/05 A copy of the five year wiring 31/10/05 certificate must be sent to the Commission and in future a copy must be retained at the home for inspection. All checks required by the West Midlands Fire Service (WMFS) must be undertaken. The home must furnish the Commission with how the requirements of the WMFS have been met and the requirements the inspector left on the immediate requirement sheet. 30/08/05 30/08/05 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. Refer to Standard op30 Good Practice Recommendations It is recommended that the home keep a record of the teams performance on training to enable the planning of future training.
E54 S16775 ManorHse V242467 280705 Stage 4.doc Version 1.40 Page 19 Manor House Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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