CARE HOMES FOR OLDER PEOPLE
Manor House 1 Amblecote Avenue Kingstanding Birmingham West Midlands B44 9AL Lead Inspector
Jill Brown Announced Inspection 8th December 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Manor House DS0000016775.V264485.R01.S.doc Version 5.0 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. Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Manor House Address 1 Amblecote Avenue Kingstanding Birmingham West Midlands B44 9AL 0121 360 0680 0121 325 1511 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) Servite Houses Tracey Byrne Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 28/07/05 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 ensuite 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 DS0000016775.V264485.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An announced inspection took place over 8 and half hours on a day in December. Six residents, two health care professionals and two relatives were spoken with. Twenty-three comment cards were received, 12 from residents of the home and 13 from the representatives of residents. Records of residents and staff were looked at. This inspection looked at the core areas not covered by the last inspection and is best read with the unannounced inspection that took place in July. What the service does well:
Residents spoken with and comment cards showed that there was a high level of satisfaction with the service that this home provided. Comment cards said that the home was well run, with excellent permanent staff and was a good and caring home. Health professionals spoken to thought that the home provided a good service and called on them appropriately if they had concerns about residents in their care. Health needs were met and residents were treated with respect and kindly. Medication administration was good; this protects and keeps residents well. The residents have choices based on them having an individual flatlet of their own. Residents can be as independent as their condition allows and can join in as much as they wish with communal activities or having meals in the dining room. The home takes complaints and concerns seriously and tries to address them. Not only does the home wait for complaints but also has an independent audit of their service. The home issues questionnaires of residents routinely and a representative of the provider visits at least monthly to see how the home is providing the service for the residents. The home performed extremely well in the independent audit of their service. The home provides a safe and comfortable environment for residents. Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 6 The home has over 50 of care staff trained to at least NVQ2 level and this protects residents. The home manages small amounts of residents money safely and well to assist families. What has improved since the last inspection? What they could do better:
The care plans had not had time to bed in and because of a poor design of one form the level of detail in care plans had not yet developed to the level required. This meant it had not yet successfully become a working tool for staff to be reminded of individual needs. For example it did not remind staff to put in hearing aids and so care could be inconsistent. The home had minimised the effect of turnover of staff by employing the same people provided by agencies. However relatives and residents commented on how the turnover of staff affected consistency of: - care for residents with memory loss and the laundry service. The home had adopted new policies and procedures and these needed to be adapted to match the home’s practice and local arrangements for example in the adult protection procedure it is important that the Social Services
Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 7 Department is contacted as they are the lead authority if an allegation is made. The notification of events to the Commission must give clear detailed information and accident records must cover the areas required by the Health and Safety Executive. 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 DS0000016775.V264485.R01.S.doc Version 5.0 Page 8 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 Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion EVIDENCE: Assessments at the previous inspection were good and met the standard. At this inspection the assessments of residents had been moved to the archive file. It is the intention that assessments are routinely moved to the archived file after the first six weeks. The provider needs to consider how it demonstrates that care plans are developed on assessed need and how assessments are to be reviewed. These assessments were not inspected on this occasion. Basic information collected however was available with the care plan such as details of next of kin and a list of health conditions affecting the resident. Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, & 10 Care planning was improving but lack of detail led to a number of inconsistencies in care. Health care and medication administration was good and this leads to good outcomes for residents. EVIDENCE: The home had started to revise all of its assessment and care planning paperwork and this will assist in ensuring that care plans become individual to the resident. Care plans had improved but more detail was needed to ensure that the care the resident needed was clear especially for new or relief staff. The provider had put in place a summary of care form that had not assisted the home, as the space to record the information was very restricted. The representative of the provider stated the intention for summaries of care plans to be sited in residents’ flats as a prompt to staff. It was evident that residents had been involved in drawing up the plans where possible. The lack of detail had led to some inconsistencies in care for example sometimes hearing aids were not put in or a resident didn’t have the right level of clothing on for the weather.
Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 11 Care plans at the home had life history information with the care plan, which the resident was willing to share with care staff. It is clear that this information assists staff gain knowledge of the interests of each resident. Residents had moving and handling and other risk assessments where needed. Residents were found to have contact with health professionals where the need arose. Health professionals spoken to at the inspection said that health care in the home was good. Managers at the home contacted them if issues arose but they were not contacted unduly and residents at the home seemed happy. The health professionals had brought a person to see the home to see if this was the type of place wanted. Residents had ‘flu injections where this was needed and agreed to. Residents personal hygiene needs were met and clothes were well laundered. Medication administration was good and this protects residents. Recommendations were made to improve the recording of as required medication and to check compliance of residents that self-administer medication. It was clear that the home had clear mechanisms for finding mistakes in medication administration and for ensuring these mistakes were not repeated. Residents spoken to said that the staff were kind and friendly. Residents said that staff knocked on the door before entering and their privacy was respected. Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 &15 Residents were able to exercise choices and food provision was good. EVIDENCE: Residents have the choice whether to come down to the dining room for meals or to have meals in their flats. The flats at the home generally are not furnished and residents have the option of bringing substantial amounts of furniture with them. The home will assist residents with their personal allowance if needed. The meal with the residents was liver and bacon or a stir-fry. Residents at the table with the inspector said the food was good and had improved. The food appeared well cooked and tasty. The home makes arrangements to celebrate every resident’s birthday and this happened on the day of this inspection. The home had started putting menus on the table for each day and some residents were using these. The home consults with residents about the type of food that the kitchen provides and this expected to increase over the next few months when more local variations from the contracted firms menus of food will be agreed. The current menu offers two clear choices for both lunch and dinner and a cooked breakfast was available twice a week. The home had a satisfactory food safety department visit which means food is prepared and stored well.
Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The arrangements for ensuring residents were safe and their concerns were listened to were good. EVIDENCE: The home and the Commission had received no complaints about the home since the last inspection. The home has a clear process of managing complaints but this is not reflected in their new complaints policy (see standard 37). Residents said that they were able to tell staff if they were unhappy with the service. Comment cards said that the home was good well run and the staff were helpful. The arrangements to ensure that residents were safe were good. A number of changes were required to the adult protection procedure but this is reported at standard 37. The home has a good restraint procedure and has a clear understanding of the use of bedrails locked doors and so on would be considered as restraints. The home has not had to refer a member of staff to the protection of vulnerable adults register. Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home provided a clean safe environment for residents. EVIDENCE: The home was clean and fresh at the time of the inspection. The home was designed for older people. It offers a good environment with individual flats that allow residents a degree of independence. The home is kept in good order and there is a handy man to undertake day- to- day repairs. The home had acted on all previous requirements made by the fire department and had acted on a requirement from the Commission to replace the dining room and conservatory carpets. The home was fitting close circuit television cameras (CCTV) on the outside of the building to increase security for residents following some disturbance earlier in the year. Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 15 The home had some laundry issues with a number of comments on the loss of laundry appearing on comment cards. The home has not had a laundry assistant for some time this recorded at standard 27. The homes new laundry procedure does not reflect the service the home offers and must be amended and this was reported at standard 37. Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Staffing levels were adequate but this was achieved by use of agency staff. Gaps in provision in the laundry and permanent staff cause dissatisfaction in residents and relatives. The home has a robust recruitment procedure and is improving on training and this protects residents. EVIDENCE: The home has had some difficulty in recruiting staff despite recruitment drives and have resorted to using agency staff. In the last eight weeks agency staff have worked 130 shifts. Residents and relatives have raised concerns about this. The home was continuing its recruitment drive and using regular carers from agencies as a way of combating shortages. Staff files looked had improved from previous inspections and now contained the information required. The home has above 50 of its staff trained to NVQ2 level and this protects residents. The home had a number of training events planned to up date staff the home was on the way to meet the requirements for training. The inspector found planned courses for abuse and infection control training days in the new year. The provider now has a one days induction course to give the basic information on abuse, first aid, health and safety and dementia care. The home was on its way to meeting the requirements of training.
Manor House DS0000016775.V264485.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,36,37 & 38 The management of the home is good with excellent quality assurance, supervision and performance management systems, this ensures that residents receive a good, consistent and safe service. New policies and procedures needed to be individualised to the home’s practice to ensure expectations of staff are clear. EVIDENCE: The provider had arranged for an independent quality assurance assessment and the home scored very highly on this. The provider undertakes routine regulation 26 visits on a monthly basis and reports are sent to the Commission as required. The home has started to become involved in peer monitoring by inspecting other homes in the organisation and this is good practice. Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 18 Residents’ money was appropriately managed. The home has a clear system for accounting for residents’ money, receipts are kept and balances checked both by the home and on occasions by a representative of the provider. The home ensured that large balances of money were not kept within the home. Residents’ money balanced with the record on the day of the inspection. Staff records showed that supervision is now being undertaken with a target of every two months being achieved on the files looked at. The supervision records were appropriate and discussed issues that would improve the care to residents. In addition there was clearly noted any issue that had to be discussed with individual members of staff and this was a clear indicator that staff were being performance managed. The provider has been developing a number of policies and procedures with an organisation. These policies and procedures need to be read and audited to ensure they meet the home’s practice and any local guidelines. For example the new adult protection procedure does not clearly state that social services must be contacted as they are the lead agency for adult protection and the complaints procedure had positive and negative complaint procedures and referred to a further complaint procedure that was not available. Records of resident’s accidents did not have the level of information required and the subsequent notification to the Commission varied in quality. It was agreed that the home should use the available resident incident form in future. It was clear from a conversation that some relatives had specific concerns about staffing levels in case of fire and needed to be reassured about the fire procedure and how this is managed in care homes. Manor House DS0000016775.V264485.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 4 X 3 3 2 2 Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 20 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. (This remains outstanding since 28/02/05) The arrangements for the recruitment of permanent staff must continue including the provision of a laundry assistant. The home must ensure that all staff complete the required training in line with the National Training Organisations guidelines. (These requirements remain outstanding since 31/03/05) The home must review all the new policies and procedures to ensure that they reflect practice in the home and local agency guidelines. Policies looked at and needed revision were: • Complaints • Adult protection • Laundry The home must ensure the appropriate level of information is provided to the Commission
DS0000016775.V264485.R01.S.doc Timescale for action 31/03/06 2. op27 18(1)(a) 31/01/06 3. op30 18(1)(c) 19 2(4) 28/02/06 4 OP37 13(4)(c) 31/03/06 5 OP38 37 31/01/06 Manor House Version 5.0 Page 21 on accident or incident in the home and detailed information on accidents is kept. 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 3 Refer to Standard OP9 OP9 OP38 Good Practice Recommendations It is recommended that as required medication is recorded in fuller detail on the reverse of the medication administration record. It is recommended that compliance checks of selfadministration takes place sometimes mid cycle to ensure a full picture of compliance is gained. The home must revise the level of information given to residents and their representatives on the fire procedures to allay concerns. Manor House DS0000016775.V264485.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Birmingham 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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