Inspection on 14/12/05 for Reinbek

This inspection was carried out on 14th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Reinbek 23/03/09

Reinbek 18/02/07

Reinbek 13/06/05

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 Cheshire SK3 8TB Lead Inspector Kathleen Mcall Unannounced Inspection 10:40 14 December 2005 th 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 Reinbek DS0000008582.V264917.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. Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Reinbek Address 287 Bramhall Lane Davenport Stockport Cheshire SK3 8TB 0161 483 5252 0161 456 0199 reinbet@boroughcare.org.uk 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) Borough Care Limited Mrs. Ines Kirby Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44), Physical disability over 65 years of age of places (10), Sensory Impairment over 65 years of age (4) Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A minimum of three waking staff must be on duty every night. Date of last inspection Brief Description of the Service: Reinbek is a residential care home that is registered to provide care for up to forty-four residents, specialising in providing care for older people with physical disabilities and sensory impairment. The home is one of twelve homes owned by Borough Care Limited. Mrs Ines Kirby is the registered manager of the home. Reinbek provides permanent residential care and short-stay accommodation. Day care facilities are available for up to four service users per day, Monday to Sunday. 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. The home is comfortably furnished and decorated throughout, the main entrance and two of the downstairs lounges were part of the original building. Accommodation is provided in forty-four single rooms, twenty-two of which have en-suite facilities. The home is structured into four units; each unit has its own kitchen, dining room and lounge facilities. The home had extensive gardens, with a large garden pond and water feature. Many of the bedrooms and lounge areas over look the garden area, providing pleasant views. The garden is easily accessible via four exits from the home, each of which has 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 DS0000008582.V264917.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over the course of a day. The registered manager accompanied the inspector throughout the inspection process. Care plans, assessment documentation, medicines and their storage were examined. The inspector spoke with several residents who were in the home at the time of the inspection and spoke with members of staff who were on duty. The inspector met four relatives who were visiting the home and had a telephone conversation with another relative. Residents told the inspector they were happy with the care they received. The inspector met and spoke with eight care staff, the cook and a kitchen assistant, who were on duty during the course of the inspection and observed that care staffs approach towards service users was sensitive and caring at all times. The home was in the process of being decorated for Christmas and hand bell ringers were visiting the home, providing Christmas music and carols for a group of service users. Residents comments about the home included some of the following statements, ‘staff are very kind’, ‘they look after you’, ‘they are kind to everybody’ and ‘they are smashing everyone of them.’ One relative told the inspector that the standard of care at the home was, ‘fairly consistent’ and said ‘I can leave my mother knowing she is safe.’ What the service does well: Reinbek is a large home that specialises in meeting the needs of residents who have a physical disability and thus it has been designed with this in mind and is very spacious. The atmosphere of the home is relaxed and friendly it offers a flexible routine based around the needs of the residents, with many residents being fairly independent and preferring to spend time in their bedrooms. Residents spoke positively about the food and were pleased with the choice and variety on offer. Residents appeared to be well cared for and were supported by a trained and competent staff group. Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 6 There have been no complaints at the home since the last inspection and one resident told the inspector that she had no need to complain. 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 DS0000008582.V264917.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 Reinbek DS0000008582.V264917.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): 3 and 4 Service users care needs were fully assessed before admission and they were satisfied with the care provided. EVIDENCE: There had been a number of new service users admitted to the home since the last inspection. Those service users recently admitted to the home had been assessed prior to their admission. Assessments were obtained from social workers and health professionals if they had been involved in the admission. Service users recently admitted to the home told the inspector that they were happy with the way in which the home was meeting their needs. One service user described care staff as ‘very kind’ and said that staff looked after him. One relative told the inspector that he felt care staff had a good understanding of his mothers care needs and that he was very satisfied with the standard of care provided. Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 9 Care staff demonstrated a good understanding of service users care needs and were observed to have a pleasant manner with service users. Reinbek DS0000008582.V264917.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 and 10. Service users health and personal care needs were identified and met. EVIDENCE: Care plans seen were individualised to each service users’ care needs with information held in one accessible document. Care plans included health needs, personal care needs, mobility, social interests, and risk assessments and were reviewed on a monthly basis and any changes needed were included. Daily records were detailed and concise and gave a full picture of how the home was meeting service users care needs and how service users had spent the day. Service users care plans were stored in their bedrooms. This system had been introduced at the time of the previous inspection and initially there had been some difficulties with service users adjusting to staff recording on care plans in their bedrooms. These difficulties had now been resolved and service users and staff were comfortable with this arrangement. Reinbek had specialist equipment in place to meet the needs of service users. Service users confirmed that they had access to GP support, district nursing services, optician and chiropody services when required. A relative of a service user recently admitted to the home said she was very impressed at the way in which care staff attended to her mother’s health needs and that staff were Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 11 very quick to contact the GP if they were at all concerned about her mother’s health. Medication was provided in the monitored dose system. On examination of medication records it was found that there were occasions when the amount of medications recorded, as being in the home did not correspond with the actual amount. In one incidence missing medication was found to have been administered on a previous MAR sheet, but this information had not been carried forward, which led to the confusion. The registered manager addressed this by putting a new system in place. However two further incidents of medication amounts being incorrect were found. The registered manager must review the homes procedure for checking and counting medicines brought into the home. Service users told the inspector that staff treated them well and they were very satisfied with the care they received. Care staffs approach towards service users was observed to be respectful, sensitive and caring at all times. Reinbek DS0000008582.V264917.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): 12, 13, 14 and 15. The day-to-day routine of the home including mealtimes was relaxed and informal and met service users needs. EVIDENCE: The day-to-day routine of the home enabled service users to spend time in their rooms or the lounge areas. Service users said they could get up and go to bed at times that suited them and that the day was theirs to spend how they choose. There was 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. At the time of the inspection the home was in the process of being decorated for Christmas and a band of hand bell ringers were visiting the home, providing Christmas music and carols for a group of service users. Several relatives were visiting the home to join service users in the activity. One relative told the inspector that he regularly visited the home and arranged a game of bingo for service users. Some service users chose not to join in the activities downstairs and preferred to stay on the units. One relative told the inspector that she thought this could Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 13 sometimes be a barrier to her mother going downstairs for activities and said she would like care staff to be mindful to include her mother. The registered manager was made aware of this and said every effort would be made to ensure that all service users were invited to attend activities. Service users confirmed that visitors were made welcome at the home and service users kept in touch with family and friends. A number of relatives and visitors were in the home at the time of the inspection. Service users told the inspector that they enjoyed the meals provided at the home; lunch was the main meal of the day, the teatime meal was a light snack meal and breakfast could be taken in service users bedrooms or in the dining room areas. The inspector observed the lunchtime meal, which was well presented and freshly made. Service users told the inspector that they had enjoyed their lunch and that the meals provided were very good and, that a wide choice was available. Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 Service users felt confident that their complaints would be taken seriously and acted upon. The majority of staff had undertaken appropriate training in adult protection. EVIDENCE: The home had a detailed complaints policy and procedure; there had been no complaints since the last inspection. 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. The home had a procedure for responding to allegations of abuse. As required at a previous inspection the majority of care staff had completed training in adult protection and further training was planned for early 2006. Care staff on duty at the time of the inspection demonstrated a good understanding of issues around adult protection. Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 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 the following standard(s): 19, 24 and 26. The home was well maintained and provided comfortable living accommodation for service users. EVIDENCE: The home was well maintained throughout and provided comfortable accommodation. The grounds of the home were well kept and attractive. The home was clean, tidy, bright and airy throughout and was free from any unpleasant odours, with the exception of room 44 which had an odour problem. The registered manager told the inspector that the room was cleaned on a regular basis and that they were considering a number of measures to help control and eradicate the odour. A number of service users rooms were seen, these were also furnished and equipped to a comfortable standard, many had been personalised by the occupants, with many of the service users being quite self contained in their own rooms. Service users were offered a key so they could lock their rooms. Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 16 The home complied with the requirements of the fire authority. Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 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 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, 29 and 30. The home was sufficiently staffed with a staff group that was trained to undertake their duties. EVIDENCE: At the time of the inspection the home was 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. Since the last inspection three new members of staff had been employed at the home. The registered manager had followed thorough recruitment procedures in regard to newly appointed staff. New staff had completed a period of induction at the commencement of their employment. The inspector met one new employee who was on duty at the time of the inspection who confirmed that she had completed a three-day induction course including POVA training. Existing staff confirmed that they had undertaken further training to assist them in their role as carers, including moving and handling updates, food hygiene, fire training, POVA and the safe handling of medicines. The inspector had a discussion with a relative who was concerned that staff did not understand how to manage her relative’s diabetes. The inspector had a discussion with the cook who confirmed that she had completed training in Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 18 providing specialist diets and ensured that diabetic options were provided at all meal times. Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 19 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, 33, 35, 36 and 38. The home was well managed for service users and care staff were appropriately supervised. The health and safety of staff and service users was safeguarded. EVIDENCE: 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. At the previous inspection the registered manager was required to continue to review the quality of care provided at the home and supply to the commission and service users a report of the findings of the review. At the time of this inspection the home had not made any further developments towards meeting this requirement. Reinbek had a number of means of seeking feedback from Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 20 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. Staff received regular supervision to support them in their work and records of such meetings were made available at the time of the inspection. The home did not have any involvement with service user finances; these remained the responsibility of service users or their relatives. Small amounts of money were held for service users to purchase small items; systems were in place to ensure the safe handling and storage of service users monies. The home complied with the requirements of the fire authority and maintained records in respect of fire safety at the home. Staff had updated their training in safe handling and moving procedures, fire safety, food hygiene and health and safety. A certificate confirming the maintenance of the stair lift was seen on inspection. The home recorded information in respect of falls and accidents by service users. Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 21 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 3 3 X N/A 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 3 X 2 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 3 X 2 X 3 3 X 3 Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 22 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 OP9 Regulation 13(2) Requirement The registered manager must review the homes medication procedure around medication brought into the home and ensure that information on MAR sheets corresponds with the amount of medication stored in the home. The registered manager must provide training in adult protection to all care staff employed at the home. (Timescale of 13/09/05 not met) The registered person must ensure that bedroom 44 is kept free from odours. 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. (Timescale of 12/10/05 not met) Timescale for action 14/12/05 2. OP18 13(6) 31/03/06 3. 4. OP26 OP33 16(2)(k) 24(1)(a)( b)(2) 14/01/06 31/03/06 Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs 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. Extracts may not be used or reproduced without the express permission of CSCI Reinbek DS0000008582.V264917.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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