Inspection on 30/11/05 for Olivet Christadelphian Care Homes

This inspection was carried out on 30th November 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.

Other inspections for this house

Olivet Christadelphian Care Homes 14/08/08

Olivet Christadelphian Care Homes 05/09/06

Olivet Christadelphian Care Homes 19/07/05

Olivet Christadelphian Care Homes 07/01/05

Olivet Christadelphian Care Homes 15/06/04

Olivet Christadelphian Care Homes 17/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Olivet Christadelphian Care Homes 17 Sherborne Road Acocks Green Birmingham West Midlands B27 6AD Lead Inspector Lisa Evitts Unannounced Inspection 30th November 2005 14:35 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 Olivet Christadelphian Care Homes DS0000024873.V270143.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. Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Olivet Christadelphian Care Homes Address 17 Sherborne Road Acocks Green Birmingham West Midlands B27 6AD 0121 683 8700 0121 683 8701 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) Christadelphian Care Homes Mrs Margaret Alison Maylin Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (60), Sensory Impairment over 65 years of age (60), Terminally ill over 65 years of age (60) Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of beds is 60, of which 31 may be for nursing care and 29 for residential care Males and females over the age of 65 years That one named service user under the age of 65 can be accommodated and cared for within this home for reasons of old age 19th July 2005 Date of last inspection Brief Description of the Service: Olivet provides nursing and residential care for up to 60 persons of 65 years of age or above and the service is exclusively offered to those of the Christadelphian faith. The home is situated on a site that also provides sheltered housing and operates as part of the Christadelphian Nursing and Residential Care Organisation and has other establishments around the country. There is sufficient off road parking for 27 vehicles as well as a dedicated space for the visiting GP. The home has an attractive enclosed garden area to the rear of the property, which service users have access to. The premises are close to public transport links to the city centre and within walking distance of a range of local amenities. Nursing and residential areas are located in separate wings of the building; the nursing area is a recent build and has a dedicated section for care of those suffering from dementia. The home has three shared rooms with en-suite facilities. The remaining single rooms, with the exception of one room have ensuite facilities and these have recently been upgraded to include a walk in shower facility. Each wing has a lounge and there are a number of dining and bathing areas, the home also has on site kitchen and laundry facilities. Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by two inspectors, over an afternoon, and were assisted throughout by the nurse in charge. On the day of the inspection there were 55 people living at the home, 25 on the residential unit and 30 on the nursing unit. Information was gathered from speaking to residents and staff, observing care staff perform their duties and from examining care and health and safety records. This is the second statutory inspection for the 2005/2006-year and it is recommended that this report is read in conjunction with the previous report. What the service does well: What has improved since the last inspection? The management of medication on the nursing unit has improved. The home has implemented the use of a nutritional risk assessment tool which will assist in ensuring residents receive the care that they require for nutritional needs. Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 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. Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 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 Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 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 the following standard(s): 1, 2, 3 The assessment and admission processes are comprehensive and this ensures that the prospective resident has all the information about Olivet in order to make an informed decision as to whether they would like to live at the home. Residents are provided with an agreement as to terms and conditions of residency. EVIDENCE: The organisation has produced a service users guide and a statement of purpose, which has all the relevant information about the home. An agreement of terms and conditions of stay at the home was reviewed and was found to contain all the relevant information, including the fee and the room number to be occupied. The home offers an eight-week trial period, which could be extended depending on individual cases. This would be negotiable with the Registered Manager. Senior staff undertake pre admission assessments for all prospective residents and these were found to be comprehensive. Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 Resident’s health and personal care needs are well met by the care staff. Improvements are required in respect of care planning to ensure that they include sufficient detail for staff to follow in order to meet the identified needs of the residents. EVIDENCE: Senior staff at the home undertake comprehensive pre admission assessments, and this ensures that the home can meet the assessed needs of the individual. The home is currently in the process of changing over to a computerised system for generated care plans and it is recognised that there will be some problems to work through in the initial stages. Some of the care plans gave specific details as to personal preferences and needs but this was not consistent across the files reviewed. The computer generated care plans were “core plans” and these had not always been individualised to the person and therefore it was confusing to follow, as specific details were not clear. Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 10 Care staff complete a personal hygiene sheet on a daily basis and this covers all aspects of care undertaken. There is evidence that residents are seen by visiting healthcare professionals and there is a separate sheet to record this, which assists with ease of monitoring. Tissue viability and moving and handling risk assessments had been undertaken, and the home has implemented the use of a nutritional riskscreening tool. One resident was observed to have bed rails on the bed, without the use of bumpers for protection and this poses a potential risk of injury to the resident. An immediate requirement was left that all residents who require bed rails must also have bed rail protectors in place to minimise the risk of injury, unless the resident does not wish to have protectors and it is safe to agree their removal, which should then be documented. Daily reports were reviewed and found to be very detailed including information about activities engaged in and any care or treatment changes for the resident. Identified problems were not always followed up with instructions in the care plans. Residents appeared to be very well supported to meet their personal hygiene needs and to choose appropriate clothing for the time of year. At the previous inspection information pertaining to residents health care needs was on display in the nurses office and it was visible from the main corridor. It was pleasing to see that an alternative location had been sought in respect of this. Medication was not fully reviewed on this occasion, however requirements made at the last inspection were reviewed on the nursing unit. The requirements had been addressed with the exception of one, which was partly outstanding. Some medications had not been recorded on receipt into the home. Photocopies of prescriptions are kept in a separate folder and it is recommended that these are kept at the back of the MAR chart to assist with the checking of medication and the audit process. Controlled drugs had been recorded in the appropriate manner. The medication policy requires updating with the details of how medication is to be disposed of on the nursing unit. Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not fully assessed on this occasion but were assessed on the previous inspection. EVIDENCE: On arrival at the home it was pleasing to see that several residents were taking part in a movement to music group, a staff member was also participating and giving the residents encouragement. Other residents were in their own rooms as they had chosen. Comments from residents included: “Meals are very good” “We have a choice of meal the day before” One resident stated that “The left hand top table always got meals in the same order and they were always last”. The manager has confirmed that staff do alter the order in which the tables are served and this will be further inspected on a future occasion. Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The complaints procedure is comprehensive and is accessible to the residents and their representatives should they need to make a complaint. The adult protection policy requires an amendment to ensure that residents are fully protected. EVIDENCE: CSCI have not received any complaints pertaining to the service provided by Olivet. The home had recorded two complaints since the last inspection, and the management team had resolved these. One complaint had been investigated thoroughly and there was a fully comprehensive response letter forwarded to the complainant. On the second complaint, it was documented that the family had not made a formal complaint, however the manager had investigated the concerns raised and recorded the outcome in detail. It is recommended that an audit log is implemented in order to assist in the ease of monitoring. The adult protection policy was reviewed and requires an amendment as states, “ if consent has been obtained from the victim”, and this is not in line with the Department of Health “No secrets”. Staff need to be aware that in some situations the resident may not be able to give their consent, however the situation may still need reporting to the relevant agency. A flow chart is in place for staff, to ensure the correct procedure is followed and this was very detailed. Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 Olivet provides a homely, comfortable and clean environment to live in, where residents are relaxed and secure. Resident’s rooms are individualised and provide residents with adequate facilities to meet their needs. EVIDENCE: A tour of the building was not completed, but areas seen were homely in style and found to be clean and odour free. Furniture, fixtures and fittings are all of a high standard. There is adequate seating within the home and this is arranged to promote social interaction. Residents were observed to be seated in the communal lounges whilst others had chosen to stay in their own rooms. Bedrooms seen contained many personal items and one resident said, “My room is lovely” Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 14 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, 30 The home has an appropriate skill mix and allocated numbers of staff, to offer good consistent standards of care to meet the assessed needs of the residents. Staff undertake relevant training to ensure that they work within their job role in a competent manner. EVIDENCE: Staffing rotas were taken for review and these identified that there were adequate numbers of staff on duty. The management team provide on call support for the person n charge of the shift. In addition to care staff the home also has laundry, housekeeping and kitchen staff that provide ancillary support. Residents spoken to all commented about the friendliness of the staff and one resident stated, “You couldn’t change anything”. Staff receive training for induction and have received training to include fire and infection control. One member of staff spoken to said “We have a manual handling review every year”. A number of staff have achieved the NVQ Level 2 in care. A qualified nurse stated that they had received training in the use of a pump to assist in the feeding of a resident via a PEG tube, from a community nurse. Staff spoken to were able to give comprehensive answers about the admission process into the home and this ensures that residents are welcomed on Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 15 admission. One member of staff said, “We find out their likes and dislikes and try to make them feel as comfortable as possible”. A new computer “fob in system” has been implemented for staff and the completing of weekly timesheets will be discontinued. The computer will check the times of staff working against the duty rota. Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 16 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): 31, 38 The Registered Manager ensures that a good standard of service is provided at the home. Maintenance checks of equipment and comprehensive staff training ensures that the health, safety and welfare of residents is protected. EVIDENCE: The Registered Manager is a Registered Nurse with much experience of caring for older people within a management role and holds the Diploma in the Management of Care Services qualification. The home is currently looking to employ further administrative staff to assist on the reception area, and to assist the Manager with administrative duties. Accident records were reviewed and were very detailed, with evidence that follow up action had been taken. The manager reviews all accident forms and Senior Managers also audit the forms each month to minimise further risks. Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 17 Fire records were reviewed and appropriate checks to equipment are made on a weekly basis. A recent fire drill had taken place with a practice evacuation. The fire risk assessment requires a review as was out of date. Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 18 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 2 Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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)(2) (b) Requirement Timescale for action 15/03/06 2. OP7 15(1)(2) (c) 3. OP7 14(2)a,b 15(1)(2)b 4. OP7 15(2)(b) The care planning system must be reviewed to identify individualised care planning and the care plans must be updated each time that there is a change in the care regime to be provided. (Previous timescale of 19/11/05 not met) Residents and/or their 28/02/06 representatives must be involved in the agreeing of care plans. (Previous timescales of 31/10/04, 07/05/05 and 31/10/05 not met.) Individual care plans must be 31/01/06 devised in respect of acute care needs, for example for residents that have an infection or acute medical conditions. (Not assessed on this occasion) All residents care plans must be 10/02/06 reviewed at least monthly and this must include a written review of the care needs. (Previous timescales of 22/10/04, 07/05/05 and 30/09/05 not met.) Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 20 5. OP7 13 (4)(c) 16 (2)(c) 6. OP9 13(2) 7. OP9 13 (2) 8. OP9 13(2) 9. OP18 13(6) 10. OP38 24(4) All residents who require bed rails must also have bed rail protectors in place to minimise the risk of injury. (This was received as an immediate requirement) Medication policies and procedures must be reviewed and include any new practices implemented in the home and staff must adhere to these. (Previous timescale of August 2004 not met) Protocols for when required medication should be written and should include reasons for administration, dose, maximum daily dose and dose intervals in addition to the need to record outcome. Examples of medicines that require written protocols are rectal diazepam, benzodiazepines, and antipsychotics. Quantities of all medicines received and balances carried over from previous MAR charts must be recorded. (Previous timescale of 20/07/05 not met) The adult protection policy must be amended to include guidelines from the Department of Health’s “No secrets”. The fire risk assessment must be reviewed on an annual basis. 01/12/05 24/02/06 31/02/06 31/01/06 21/02/06 31/01/06 Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP15 OP26 Good Practice Recommendations It is recommended that the alternative to the main meal option of the day is reflected on the daily menus. It is recommended that either an alternative location is sought for incontinence pads to be stored or pads are stored in a lidded receptacle to prevent the risk of cross infection in bathrooms. (Not assessed on this occasion) It is recommended that a system for the numbering and subsequent logging of individual receipts for items purchased out of residents personal allowances is introduce. Signatures should be obtained for all monies in and out of the accounts receiving nursing care at the home and there should be written documentation of the regular auditing of this system. (Not reviewed on this occasion) It is recommended that the photocopies of prescriptions are kept at the back of the MAR chart for ease of monitoring. 3. OP35 4. OP9 Olivet Christadelphian Care Homes DS0000024873.V270143.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 © 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 Olivet Christadelphian Care Homes DS0000024873.V270143.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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