Inspection on 13/06/05 for Reinbek

This inspection was carried out on 13th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Reinbek 23/03/09

Reinbek 18/02/07

Reinbek 14/12/05

Reinbek 12/01/05

Reinbek 08/07/04

Reinbek 22/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Reinbek 287 Bramhall Lane Davenport Stockport SK3 8TB Lead Inspector Kathleen Mcall Announced 13 & 14 June 2005 th th 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. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Reinbek Address 287 Bramhall Lane, Davenport, Stockport SK3 8TB 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) 0161 483 5252 Borough Care Limited Mrs Ines Kirby Care Home 44 Category(ies) of PD(E) Phyisical Disability - over 65 - 10 registration, with number OP Old Age - 44 of places SI(E) Sensory Impair over 65 - 4 Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. A minimum of three waking staff must be on duty every night. Date of last inspection 12th January 2005 Brief Description of the Service: Reinbek is a residential care home that specialises in providing care for older people with physical disabilities and sensory impairment. The home is one of 12 homes owned by Borough Care Limited. Reinbek provides permanent residential care and short-stay accommodation for up to 44 service users. Day care facilities are available for up to four service users per day, Monday to Friday. Accommodation is provided in 44 single rooms, 22 of which have en-suite facilities. The home is structured into four units; which have kitchen, dining room and lounge facilities. Reinbek is a two-story building, it is fully adapted for wheelchair users and has a lift to assist service users to the first floor of the home. Reinbek is comfortably furnished and decorated throughout, the main entrance and two of the downstairs lounges were part of the original building and are oak panelled throughout, creating a ‘country house’ feeling. The home had extensive gardens, with a large garden pond, a water feature and a pagoda. Many of the bedrooms and lounge areas over look the garden areas, providing pleasant views. The garden is easily accessible via four exits from the home, each of which had ramp access for wheelchair users. The home is located in a residential area, on the main Stockport to Bramhall Road. A regular bus service is available and the nearest railway station is Davenport station. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over the course of two days. The registered manager accompanied the inspector throughout the inspection process. Care plans, assessment documentation, medication and their storage were examined. The inspector spoke with a number of residents in the home and several members of staff that were on duty at the time of the inspection. Eight service user comment cards were returned; six cards indicated that residents like living at the home, two responded that sometimes they liked living at the home. All indicated that they felt well cared for living at Reinbek and that the staff treated them well. One resident wrote ‘staff and carers are very good and friendly’, another wrote ‘ Reinbek is very clean. The staff are very caring and always look clean and smart, always there if you need them for anything’. One other said ‘everything is of a very high standard’. Four relatives comment cards were returned, one of which said ‘regular staff very good. Agency staff poor.’ Another card indicated some dissatisfaction with the overall care provided, and expressed concern at the lack of a visual presence of staff within the home. A relative who was visiting at the time of the inspection told the inspector that she had no concerns and was quite satisfied with the way in which her relatives care needs were being met. Two GP comment cards and a comment card from a district nurse were returned. One GP’s comment card said that ‘Reinbek continues to be a centre for excellence’. What the service does well: A number of residents spoke positively about their experience of living at Reinbek and were particularly complimentary about the care staff. One resident said ‘I’m very happy, staff are a 100 , the food is a 100 , staff are perfect’. Another resident said ‘the staff are wonderful and the place is spotless’. The day-to-day routine of the home was flexible, with many residents preferring to spend their time in their bedrooms. Several residents managed their own medication and one resident said she enjoyed doing this and that it made her feel independent. Activities are provided each afternoon to both permanent residents and those on a short stay visit to the home, in the main lounge area. One relative felt that activities could also be encouraged to take place on individual units for those residents who choose to remain on the units. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 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. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 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 Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 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) 2, 3, 4 and 5. Service users had a written contract, their care needs were fully assessed before admission and arrangements were in place for them to visit the home prior to their admission. EVIDENCE: Service users recently admitted to the home had a written contract which detailed the terms and conditions of their stay. Service users were assessed prior to their admission to the home; no service users were admitted to the home without having had their care needs assessed. Assessments were obtained from social workers if they had been involved in the admission. Borough Care had its own assessment documentation called the “key-working together document”; this was completed for all new service users irrespective of their funding arrangements. Service users were assured that their care needs could be met by the home; Reinbek had specialist equipment in place to meet the needs of those service users with a physical disability. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 9 Arrangements were in place for service users to visit the home prior to their admission and have the opportunity of meeting other residents and staff. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10. Service users health and personal care needs were identified and met. EVIDENCE: Since the last inspection a new system of care planning had been introduced at the home and service users care plans were now stored in their bedrooms. This is a pilot scheme run in conjunction with the district nursing service. The majority of service users were happy with care plans being in their bedroom, two service users said they didn’t know why they were in their rooms, one service user thought it was a very good idea and said that she liked to read what had been written about her and asked that a separate sheet be included for service users comments. The registered manager put this in place during the inspection. Two other service users said staff writing in the plan late at night had disturbed them. The registered manager again responded to this and service users were given to option of having the care plan taken out of their bedroom during the evening. Staff said that they liked the new system, and thought it worked well and found that it was easier to ‘record as you go along’ rather than at the end of a Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 11 shift. Staff told the inspector that they felt the new system worked extremely well. Care plans seen were individualised to each service users care needs with information held in one accessible document. Service users were very satisfied with the way in which their health care needs were met; one service user described the care staff as ‘very attentive’. Service users had access to GP support, district nursing services and chiropody services when required. Several service users managed their own medication. Medication and the administration of medicines in the care home had improved since the last inspection. However staff responsible for administering medicines need to agree a preferred style of coding on MAR sheets that all care staff adhere to. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 15. Service users were able to exercise choice and control. Mealtime arrangements were well managed and satisfied service users expectations. EVIDENCE: The day-to-day routine of the home was relaxed and flexible with some service users preferring to spend time in their rooms and others using the lounge facilities. Some service users preferred to take their meals in their bedroom, a number of service users were quite self-contained within their rooms. Several service users managed their own medication; one service user told the inspector that she felt this allowed her to live an independent lifestyle, as much as she could do whilst living in a care home. There is an activities coordinator in post who was employed to provide activities for up to two hours each afternoon, Monday to Friday. Activities were available to both day care service users and permanent service users. Another member of staff was a trained and qualified reflexologist and aroma therapist and provided massages to service users, following consultation with their GP. Visitors were made welcome at the home and service users kept in touch with family and friends. Service users confirmed that they could have visitors at all Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 13 times. One service user said that relatives could make a cup of tea for themselves when visiting the home. Service users comments with regard to the food and meals provided were mixed with some liking and other disliking the food provided. The head cook had complied a questionnaire to seek feedback from service users regarding the quality and choice provided and hoped to respond to service users requests. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home had a complaints policy and procedure, service users were confident that their complaints would be dealt with in a satisfactory manner. Not enough staff had undertaken appropriate training in adult protection. EVIDENCE: The home had a detailed complaints policy and procedure. Service users told the inspector that they knew who to complain to and felt that their complaint would be dealt with in a suitable manner. One relatives comment card said that they were not aware of the homes complaints procedure. All complaints received at the home were recorded in a hardback book, which contained information relating to several service users. This information was not maintained in accordance with the Data Protection Act 1998. The majority of staff had undertaken training in Adult Protection however a number of staff had not and did not understand the term ‘whistle blowing’ and the implications this may have for their practice. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 15 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) 19, 21, 22, 24 and 26. The home was well maintained and provided comfortable living accommodation for service users. EVIDENCE: The home was well maintained and provided comfortable accommodation throughout. The grounds of the home were well kept and attractive. The home had a number of toilets situated close to the lounge, dining areas and bedrooms. Twenty-two bedrooms within the home had en-suite facilities. The home had two specially adapted showers for those service users who were wheelchair dependent. Specialist equipment was in place eg wheelchair ramps, grab rails were in corridors and bathroom areas to maximise service users independence. A number of service users rooms were seen, these were also furnished and equipped to a comfortable standard, many had been personalised by the Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 16 occupants, with many of the service users being quite self contained in their own rooms. The home was clean, tidy, bright and airy throughout and was free from any unpleasant odours. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 17 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 and 30. The home was sufficiently staffed with a staff group that was trained to undertake their duties. The homes recruitment procedure ensured that service users were protected. EVIDENCE: At the time of the inspection the home was sufficiently staffed to meet the needs of service users. A staff rota showing which staff was on duty and in what capacity was kept at the home. The home followed a thorough recruitment procedure in regard to newly appointed staff at the home. New staff completed a period of induction at the commencement of their employment and existing staff confirmed that they had undertaken further training to assist them in their role as carers. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 18 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) 31, 33, 36, 37 and 38. The home had a qualified and competent manager, who ensured that health and safety issues within the home were addressed. Records were not maintained in accordance with the Data Protection Act 1998. EVIDENCE: Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 19 The registered manager, Mrs Ines Kirby has approximately 26 years experience in working in the residential care sector, she has been the manager at Reinbek for about four years. She holds a Certificate in Social Services and has recently completed the NVQ Level 4 in Care Management and the Registered Managers award. Reinbek had a number of means of seeking feedback from service users and their relatives; these include review of complaints and compliments, service user and relatives’ questionnaires, the key worker system, residents meetings and staff supervision. Other information that is collated for quality assurance purposes included the number of falls and accidents on each unit. It was anticipated that this information will be made available to service users, relatives and other interested parties in the form of an annual report. A requirement in respect of this standard was made at a previous inspection with a timescale for completion for the 12.10. 05. Staff confirmed that they received regular supervision and written evidence to support this was made available at the time of the inspection. Staff had updated their training in safe handling and moving procedures, fire safety, food hygiene and health and safety. The home maintained records in respect of fire safety at the home. The home records information in respect of falls and accidents by service users, this information is stored in two sources neither of which were maintained in accordance with the Data Protection Act 1998. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 20 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 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 x 2 x x 3 2 3 Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 21 No 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 OP 9 Regulation 13(2) Requirement The registered manager must ensure that all staff use the same coding on MAR sheets to indicate if a service users has taken medication or not. The registered manager must provide training in Adult Protection to all care staff employed at the home. The registered manager must continue to review the quality of care provided at the home and supply to the commission and service users the findings of the review. The registered manager must ensure that all information stored in relation to complaints made by service users or their relatives is maintained in accordance with the Data Protection Act 1998 Timescale for action 13th July 2005. 2. OP 18 13(6) 13th September 2005. 12th October 2005. 3. OP 33 24(1)(a)( b)(2) 4. OP 16 12(4)(a) 12th September 2005. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Reinbek Refer to Good Practice Recommendations F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 22 1. Standard OP 37 The registered manager must ensure that all information stored in relation to falls and accidents by service users is maintained in accordance with the Data Protection Act 1998. 2. Reinbek F54-F04 s8582 Reinbek v224437 130605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 2nd Floor, Heritage Wharf Portland Place Ashton-under-Lyne OL7 0QD 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. 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