Inspection on 16/06/05 for Sayer House

This inspection was carried out on 16th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sayer House 29/11/06

Sayer House 18/01/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Sayer House 2 Newholmes Monyhull Hall Road Kings Norton, Birmingham B30 3QF Lead Inspector Sarah Bennett Unannounced 16th June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispin’s, 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. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sayer House Address 2 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QF 0121 443 2871 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) South Birmingham Primary Care Trust Ms Ivy Winters Care Home 6 Category(ies) of Learning Disabilities (6) registration, with number Physical Disabilities (6) of places Sensory Impairment (6) E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. A qualified Nurse must be working in the home at all times and must not have responsibilities for any of the other Newholmes bungalows. Date of last inspection 30th November 2005 Brief Description of the Service: Sayer House was previously registered as part of the Newholmes registration of six bungalows. In May 2005 the homes were registered separately. Sayer House provides nursing care to six people who have a learning disability. Some residents have additional physical disabilities, sensory impairment and dementia. Sayer House is a six- bedroom bungalow that is fully accessible to all residents. Communal areas consist of an open plan kitchen, dining room and lounge. There is an additional small room off the lounge. There is a bathroom, shower room and a separate WC. Ceiling track hoists are fitted in bedrooms and bathrooms. Adapted bathing and shower facilities are provided. To the side of the bungalow there is a garden with grassed areas, pots and hanging baskets. The garden has a fence around it making it private. The home is situated in the grounds of what was once Monyhull hospital. However, a new housing estate has been built around the bungalow which now makes it part of the local community. Family Housing Association owns the premises. The home is managed and staffed by South Birmingham Primary Care (NHS) Trust. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over five hours. The inspection included a tour of the premises. Care, staff and health and safety records were looked at. Three residents records were sampled. Six residents and five of the staff on duty were spoken to. What the service does well: What has improved since the last inspection? The home has been registered separately from the other Newholmes bungalows, which will make the service more individual for the residents. Staff have received training fire safety. A fire drill has taken place during the night so that all staff know what to do if there is a fire in the home. The emergency lighting is tested monthly to make sure it is working. Staff have been booked on training courses so they can know how to meet residents individual needs. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 6 The lounge and dining room have been redecorated. In the lounge there is a new carpet and furniture. 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. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Prospective residents needs are assessed before they move into the home to ensure their needs can be fully met. EVIDENCE: One resident had recently been admitted to the home. The manager had visited the resident and carried out an assessment prior to their admission. The manager had arranged for other professionals to assess the resident to ensure they had appropriate input to meet their health needs. The manager wrote a detailed report of their knowledge of the residents needs for staff to read. Other residents records sampled included a completed pre-admission assessment that assessed whether or not the home could meet the residents needs. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 Resident’s assessed needs and goals are reflected in their individual care plans so that staff know how to support each individual. Resident’s are supported to make decisions about their day-to-day lives. Resident’s are consulted on and informed of what is going on in the home. Residents are supported to take risks within a risk assessment framework. EVIDENCE: Resident’s records sampled included detailed individual care plans. These stated how the individual resident was to be supported by staff with their personal care, health needs, social and leisure activities, eating and drinking and at night. Two of the care plans sampled stated that the resident should be weighed weekly and referrals made to the dietician if there were any changes in their weight. However, weight records indicated that the residents had been weighed monthly. Two residents financial records were looked at. A relative was the appointee for one of the residents. The money in individual residents purses and wallets cross-referenced with the amount on their record. Receipts are kept of all purchases. Money is stored securely in the home. One member of staff is responsible for the money on each shift. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 10 Staff were observed asking residents what they wished to do and offering choices of drinks and activities. Resident’s records sampled included individual risk assessments that had been regularly reviewed and updated if there were any changing needs. The manager said that they have resident’s meetings. However, due to their needs residents are not always able to contribute. Residents are informed when a new resident is going to move into the home or if a resident dies. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 15, 17 Residents are part of the local community and participate in appropriate leisure activities. Arrangements are in place to support residents to have appropriate family relationships. Resident’s are offered a variety of food and have a healthy diet. EVIDENCE: The manager described the resident’s daily routines. Most of the residents are up and have had their breakfast by 10.30am. One resident has their breakfast in bed as staff have found this helps the resident to respond better during the day. If residents choose to they can have a rest on their bed during the afternoon. One resident goes to a day centre from Monday to Friday. A requirement has been made at previous inspections for the day shifts to be extended to 10pm. The manager said that in this home because of their needs the residents are more responsive to activities during the day and not in the evening. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 12 All residents went out for the day to Weston with staff a few days before this inspection. During this inspection two residents attended a funeral service of a resident who lived in another bungalow in Newholmes. Two residents went shopping with staff. A massage therapist visits the home weekly. Residents records sampled indicated that residents go to garden centres, on day trips, walks, to parks, pubs, restaurants and shopping. An accessible minibus is provided for residents use. One resident went to Disneyland Paris in March with support from staff. Staff said holidays are planned for the other residents in August and October this year. Staff spent time sitting and talking to residents. Where appropriate staff gave residents a hand and foot massage. Where appropriate residents have contact with their family. Staff said that relatives visit the home and are invited to any meetings held about the resident. Resident’s records sampled included minutes of resident’s reviews where their relatives attended and were involved in the discussions concerning their welfare. Menus and records of food provided indicated that a variety of food and drink is offered to residents. There were adequate food stocks in the home. Residents records sampled indicated that the Speech and language therapist are involved with residents where appropriate to offer support with their eating and drinking skills. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Residents receive personal support in the way they prefer and require. Residents physical and emotional health needs are met. Arrangements for the administration of medication are not always adequate to ensure residents are protected from harm. EVIDENCE: Resident’s records sampled included manual handling risk assessments, which detailed how staff are to support residents with moving and what equipment should be used. Staff were observed asking other staff to assist to move residents as detailed in residents assessments. Resident’s records sampled included details of health appointments they had attended. Pressure area assessments were in place. Where residents were assessed as being at high risk of developing a pressure sore referrals to other health professionals were made to ensure pressure - relieving mattresses were available and residents received appropriate nutrition. Residents records sampled showed that other health professionals are involved in the care of residents. Health Action Plans are not available for individual residents. Medication is stored in a locked cabinet. Boots supply the medication to the home using the monitored dosage system. Medication administration records sampled cross – referenced with the blister packs. Controlled drugs are stored in a separate locked cabinet. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 14 Drugs are checked and signed by two staff and this is recorded in the Controlled Drug Register. The amount recorded in the register cross-referenced with the amount in the controlled drug cabinet. Protocols that state when, why and how PRN (as required) medication must be given were not in place for all, as required medication. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Arrangements to protect residents from abuse are not adequate. EVIDENCE: Staff have not yet received training in adult protection and this is outstanding from previous inspections. The manager said that this training is booked for August 2005. The Trust policy on adult protection is not in line with the Birmingham MultiAgency Guidelines on Adult Protection. However, the policy writers have reviewed this and it has been forwarded to the CSCI for comment. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28, 29, 30 Residents live in a clean, homely and comfortable environment that meets their needs. EVIDENCE: The lounge and dining room have recently been redecorated. The carpet and the chairs in the lounge have been replaced. The manager said that a quote has been obtained to replace the carpet in the hall. Resident’s bedrooms were decorated according to individual tastes and contained many personal possessions. One resident’s bedroom was in need of redecoration and the carpet needs replacing. The carpet also needs replacing in another resident’s bedroom. The flooring in the shower room was rising in places. The manager said that the shower drains away sufficiently when the shower gate is used. An adapted bath is provided in the bathroom, as are hoists, which were all in working order. The washing machine was not being used as the pump was broken. Staff were taking the washing to bungalows 1 & 3. Staff said that a new pump had been ordered a week ago. The home was clean and free from offensive odours. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 The arrangements for staffing the home have a number of weaknesses that could compromise the health and safety of residents. All staff have not received the training necessary to enable them to meet all residents individual needs. EVIDENCE: Staff rotas were looked at. These indicated that on each shift there are three care staff and a qualified nurse on duty during the day. At night there is one qualified nurse and one care staff on duty. The manager said that at night the qualified nurse often has to administer the medication at Newholmes bungalows 1 and 3. Also, during the day sometimes between the hours of 8am – 9.30am and 6.30pm – 8pm the qualified nurse is responsible for holding the medication keys for Newholmes 4 and advising care staff if there are any nursing needs. Newholmes 4 is not close to Sayer House. The condition of registration of Sayer House is that a qualified nurse must be working in the home at all times and must not have responsibility for any of the other Newholmes bungalows. The manager said that there are two staff vacancies, one during the day and one at night. The manager said that training in palliative care and Alzheimer’s is regularly provided for staff. Staff from a local hospice provide some training for staff. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 18 Staff training records indicated that staff receive training in health and safety, first aid, food hygiene and manual handling. The manager said that training for staff in adult protection is booked in August 2005 and epilepsy training is booked in December 2005. The manager is doing the ‘End of Life Pathway’ course and will be undertaking a two - day palliative care course at the end of June 2005. The manager and staff said that all new staff now complete the Learning Disability Award Framework (LDAF) training. The manager said that the speech and language therapist provides in–house training for staff on managing residents who have dysphagia. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The safety and welfare of residents is not always adequately promoted or protected. EVIDENCE: Fire records were looked at. These indicated that staff test the fire alarm weekly and the emergency lighting monthly to make sure they are working. Fire drills take place at least every six months to make sure that everyone knows what to do if there is a fire in the home. Fire drills also take place at night. All staff receive regular training in fire safety. Staff carry ‘Scope’ alarms so that they can alert other staff if they need help with a resident without leaving the resident on their own. Staff test these regularly to make sure they are working. Two of the four alarms were not working as they need new batteries. The manager said that it is difficult to find shops that stock the batteries but they would keep trying. The employer’s liability insurance certificate expired in March 2005. The manager said that they have been chasing this up with the Trust but as yet have not received a new certificate. E54 S62605 V234812 160606 - Sayer House 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 Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 2 3 3 3 Standard No 11 12 13 14 15 16 17 x x 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x x 1 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 21 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 6, 19 Regulation 12 (1) (a), 15 (2) 12 (1) (a) (2) 12 (1) (a), 13 (2) 16 (2) ( c), 23 (2) (b, d) 16 (2) ( c) , 23 (2) (b, d) 23 (2) (b) 16 (2) (e) Requirement All care plans must be consistently followed to ensure that all the health needs of residents are fully met. Each resident must have a Health Action Plan in line with Valuing People. PRN (as required) protocols must be available for all as required medications(Previous timescale not met). The carpet must be replaced in the identified residents bedroom. The identified residents bedroom must be redecorated and the carpet must be replaced. The flooring in the shower room must be refitted or replaced as necessary. The washing machine must be repaired. Timescale for action Immediate & ongoing 30th September 2005 31st July 2005 31st August 2005 30th November 2005 31st July 2005 23rd June 2005 as stated on the Immediate Requireme nt sheet left at the inspection Immediate & ongoing Page 22 2. 3. 19 20 4. 5. 6. 7. 26 26 27 30 8. 33, 42 10 (1),12 (1) (a), There must be a qualified nurse on duty at all times in the home. E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 18 (1) (a) 9. 10. 11. 33 35 42 18 (1) (a) 13 (6),18 (1) (a, c) 13 (4) (a, c), HSWA 1992 Qualified staff must not be moved to other bungalows. Staff vacancies must be recruited to. All staff must receive training in adult protection (Previous timescale not met). The batteries for the Scope alarms must be replaced. 12. 42 Employers A valid certificate of employers Liability liability insurance must be Insurance available in the home. Act, 13 (4) ( c) 30th September 2005 31st August 2005 & ongoing 30th June 2005 as stated on the Immediate Requireme nts sheet left at the inspection 31st July 2005 & ongoing RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations E54 S62605 V234812 160606 - Sayer House Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 1st Floor Ladywood House 45-56 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. 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