Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 16/11/06 for Selly Wood House Nursing Home

Also see our care home review for Selly Wood House Nursing Home for more information

This inspection was carried out on 16th November 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

The environment had been further enhanced by a programme of redecoration that is almost complete, and the floor covering in the dining room had been replaced. A useful booklet had been produced informing residents about the various aspects of care home fees. The home has implemented a quality assurance system, and both residents and staff were actively involved in the quality assurance group. Residents opinions have been sought on a range of topics affecting their daily lives and changes implemented as a result.

What the care home could do better:

Pre-admission assessments needed to be documented to ensure that a judgement could be made about whether the home would be able to meet the needs of prospective residents. The Service User guide needed to be made available in a format suitable for all intended residents so that the information was also accessible to people with visual impairments. Risk assessments needed to be carried out on each resident being considered for use of bed-rails to ensure that there were strategies in place for minimising any identified risks. The recording of information in resident`s records needed to be further improved to ensure that all necessary information was available to staff caring for residents. Greater clarity was required about the adult abuse policy, and staff needed training in the prevention of abuse and responding to allegations of abuse of vulnerable people, in order to protect residents. A system of providing staff with supervision at least six times a year needed to be introduced, in order that staff could be further supported to meet the needs of the residents.

CARE HOMES FOR OLDER PEOPLE Selly Wood House Nursing Home Selly Wood Road Bournville Birmingham West Midlands B30 1TJ Lead Inspector Elizabeth Mackle Unannounced Inspection 16th November 2006 09:30 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 Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 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. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Selly Wood House Nursing Home Address Selly Wood Road Bournville Birmingham West Midlands B30 1TJ 0121 472 3721 0121 414 0731 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) Bournville Village Trust Patrick Joseph O`Keeffe Care Home 44 Category(ies) of Dementia - over 65 years of age (44), Old age, registration, with number not falling within any other category (44) of places Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 44 beds of which 24 are for nursing care and 20 for residential care The home may accommodate one named service user for the reasons of mental disorder, MD(E). 28th November 2005 Date of last inspection Brief Description of the Service: Selly Wood House provides nursing and residential care for up 44 persons of 65 years of age or more. The home is owned by Bournville Village Trust and is situated on the Trust land within the suburb of Selly Oak, South Birmingham. The building is set in a pleasant quiet residential area and has sufficient off road parking to accommodate eight vehicles. The main communal rooms are situated on the ground floor. Bedrooms are located on all three floors with both upper floors providing small lounges for residents use. Care can be provided for persons with limited mobility and wheelchair users. There is a shaft lift for access to each floor, assisted bathing facilities located on all floors, mobile hoists and a call system. All bedrooms are single status, seven of which include en-suite facilities. Toilets are situated directly adjacent to each bedroom. The home has an attractive garden that may be accessed from the front of the premises or the ground floor lounge. There is a small parade of shops nearby and bus and rail services are within fairly close proximity. The scale of charges at the home ranged from £425 - £610 per week. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place, the home had submitted a range of written information which provided good back-ground information about the home. The visit was carried out by one inspector over the course of one day in November 2006. This was the home’s key inspection for the inspection year 2006-2007. During the course of the visit a tour of the premises was undertaken and the inspector was briefly introduced to many of the residents. A variety of documentation was viewed; this included a sample of four health care records of residents, a sample of four personal files of staff members, a range of policies and procedures and other relevant records. The inspector spoke with four residents and five members of staff. The home had recently experienced a number of management changes. A new general manager had been appointed earlier in the year with responsibility for financial matters and the ancillary departments, and a registered manager had recently been appointed with responsibility for all aspects of care within the home. At the time of the fieldwork visit the general manager was on leave, and although the registered manager was not on duty, he attended the home and made himself available for part of the fieldwork visit. What the service does well: Residents were provided with a good standard of accommodation throughout the home, which was comfortable, homely and well furnished, and this helped enhance their quality of life. Prospective residents were able to visit the home in order to assess the facilities, in a way that suited their individual needs. Residents were very happy with the service they were receiving at the home. Comments included: “The attention they give you is great.” “The food is excellent – we have a choice”. “I can’t talk too highly of the staff”. “I value the fact that during the night the nurses will quietly open the door and make sure I’m alright”. Residents were treated with courtesy and respect and enjoyed good relationships with the staff. Systems had been developed which ensured that the views of residents were canvassed and acted upon, and this helped to ensure that residents felt able to effect changes within the home. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 6 Residents were pleased with the standard of food and the variety available to them. Catering staff displayed a sensitive understanding of the importance of food in the daily lives of residents. There were no rigid rules or routines in the home, and residents were able to spend their time as they wished. A wide variety of social activities were on offer, together with opportunities for religious observance. The home had robust systems in place for recruitment of staff and for dealing with complaints; these helped ensure that residents were protected. What has improved since the last inspection? What they could do better: Pre-admission assessments needed to be documented to ensure that a judgement could be made about whether the home would be able to meet the needs of prospective residents. The Service User guide needed to be made available in a format suitable for all intended residents so that the information was also accessible to people with visual impairments. Risk assessments needed to be carried out on each resident being considered for use of bed-rails to ensure that there were strategies in place for minimising any identified risks. The recording of information in resident’s records needed to be further improved to ensure that all necessary information was available to staff caring for residents. Greater clarity was required about the adult abuse policy, and staff needed training in the prevention of abuse and responding to allegations of abuse of vulnerable people, in order to protect residents. A system of providing staff with supervision at least six times a year needed to be introduced, in order that staff could be further supported to meet the needs of the residents. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents had the information they needed to assist them in making an informed decision about whether they wished to live in the home. The lack of written records relating to pre-admission assessment of prospective residents meant that it was difficult to demonstrate that the home would be able to meet the needs of the individual. Prospective residents were able to spend time in the home before making a decision to move there, and this enabled them to have some knowledge of what life in the home was like. EVIDENCE: The home had a comprehensive Statement of Purpose that was clearly displayed on a notice board in the foyer of the home. However, some of the information, for example in relation to the management arrangements within the home was out of date. This needed to be up-dated to ensure that prospective residents and relatives had accurate information. A Service User Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 10 Guide “Welcome to Selly Wood House” was also available and this was informative and easy to read. The Service User Guide was not available in other formats, such as large print or Braille; this would be particularly useful as the home had a number of residents with varying degrees of visual impairment. The care records of two recently admitted residents to the home were viewed. There was no documentary evidence that a pre-admission assessment had been carried out. The inspector was told that the registered manager usually carries out assessments, although other registered nurses were also involved in this process from time to time. It is essential that no service user moves into the home without having had his/her needs assessed and documented, using a recognised assessment tool, and that he/she has been assured that these needs can be met by the home. Prospective residents have the opportunity to visit the home before making a decision, and the arrangements for this are tailored to suit the needs of the individual. People had an opportunity to spend a few hours in the home meeting staff and residents, have a meal, or spend a longer period if they wished. Intermediate care is not provided by the home. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The delivery of general care and health care was good, with each person having an individual care plan; however the absence of risk assessments for use of bedrails may potentially place some residents at risk. The systems for the administration of medication were good with clear arrangements in place to ensure that residents’ medication needs were met. Residents were cared for in a respectful manner ensuring that their dignity and self esteem were maintained. EVIDENCE: The care records of four residents were sampled. The preferred mode of address was clearly documented. A “Resident Information Sheet” contained in the records was not always fully completed, or signed and dated by the person admitting the resident. The home had also devised a useful “Life History” and “This is Me” section in the care records to be completed by the resident, with assistance if required from family or staff. These were not always being completed. Each resident had a personal care plan and reviews had been carried out approximately every month. Care needs were clearly recorded Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 12 together with the nursing/care action required, and goal. Of the records viewed, it was noted that a number of risk assessments had been carried out, for example, falls, moving and handling, nutrition, pressure areas. However, there were no risk assessments in relation to the use of bed-rails, nor was written consent being obtained from the resident or representative. It is important to carry out appropriate risk assessments before using bed rails to ensure that all the risks have been considered before reaching a decision. There was evidence within the records that residents weight was being monitored, and that other observations were carried out regularly such as urine testing and recording of blood pressure. Staff made daily entries in care records about the general condition of each resident. Residents were reviewed regularly by their general practitioner, and brief records of this were available. It was clear from discussions with staff that residents also had access to a range of other health professionals such as chiropodists, opticians (both private and NHS), district nurses etc. but there was no record of this within the care records viewed. A local NHS dentist used by the home had recently gone into private practice and the home was in the process of registering a number of residents with another local NHS dentist. One resident said “the attention they give you is great; I’ve been very well looked after. Another resident said “I can’t talk too highly of the staff” and “I value the fact that during the night the nurse will quietly open the door and make sure I’m alright”. At the time of the inspection there were no residents who wished to take responsibility for managing their own medication. The arrangements for the storage and administration of medicines was satisfactory. A monitored dosage system was in use and staff reported no problems with this. Other “stock” medicines were audited at the end of each day. There was a clinic or storage area and a controlled drugs cupboard on each floor in the home. Medicines for disposal were securely stored and collected every two weeks. Daily temperature recordings were kept in relation to the drugs fridge. A list of homely remedies was available detailing drugs which could be administered by qualified nurses for short term use. It was noted that this was dated April 2003; it is recommended that the list is reviewed at least annually to ensure that it continues to meet the needs of residents. Throughout the course of the inspection staff were observed to be interacting with residents and relatives in an appropriate, respectful and caring way; all the indications were that the privacy and dignity of the residents was being respected. Residents who wished to spend time on their own in their rooms were able to do so and there were a number of areas where residents were able to receive visitors in private. A private telephone kiosk was available on the ground of the floor and a number of residents also had a telephone installed in their room. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The range of social activities provided in the home helped to enhance the quality of life for the residents. The dietary needs of residents were well catered for with a balanced and varied selection of food available that met their needs and tastes. EVIDENCE: Residents who conversed with the inspector expressed general satisfaction with the range of activities available to them in the home. An activity organiser was employed 30 hours per week, and a programme of activities was in place and clearly displayed. On the afternoon of the inspection a singer had been booked and residents were observed to be enjoying the session and joining in songs from the 1940s and 1950s. A visiting craft therapist attended the home regularly. Residents were able to go out shopping and for walks locally as they wished. Religious observance was encouraged and supported, and a Society of Friends (Quaker) meeting was held in the home once a week; this was also attended by a small number of people who live in the local community. Christian services also take place regularly and the home had strong links with a local Methodist church. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 14 The home had a small shop on the ground floor, stocking items toiletries, confectionery and Christmas cards etc. A small library was housed in the ground-floor lounge and this was serviced by Birmingham City Council Library Service. A range of large print books was available. A barber attended the home every month, and two hairdressers were available in the home each week on different days. A Suggestion Box was available and the Activities Organiser advised residents of the outcome of any suggestions made. Volunteers were available in the home on two days per week, and were involved in activities such as current affairs discussions and playing board games with residents. Daily newspapers were in evidence in residents’ rooms throughout the home. There were no undue restrictions on visitors to the home. A number of relatives and visitors were observed to be visiting freely and in a relaxed manner. The kitchen area was viewed, and discussions held with one of the two chefs. Staffing levels were good with one chef on duty from 8 am until 3.30 pm, and another chef from 12.00 noon until 7.30pm. In addition there were three kitchen assistants. Standards of hygiene in the kitchen were found to be high with records kept of all daily and weekly cleaning duties. The home had two fridges, and a “walk in” fridge was to be installed in the near future. Food in the fridges was appropriately labelled and dated. Temperature records for fridges were also maintained. Supplies were plentiful and storage arrangements appropriate. Fresh fruit and vegetables are bought locally, and delivered twice weekly. Meat was bought from a local butcher, and delivered twice a week. The chef felt that both these arrangements allowed for greater flexibility. Home baking was done on the premises; snacks and fresh fruit were available throughout the day. The dining room was a very spacious, pleasant room which provided residents with a pleasant environment to have their meals and for occasional functions. The floor covering of the dining room had been recently replaced. The menu operated on a three week rolling programme, and demonstrated that residents received a wholesome and varied diet. For breakfast residents could choose from a selection of cereal or porridge, and any combination of sausage, eggs, beans, tomatoes. The chef displayed a good knowledge of the likes and dislikes and the special dietary needs of residents, and was confident that the kitchen would be able to meet any religious/ethnic dietary needs that may be required. There was a list of the birthdays of all residents, and residents were able to order a special meal of their choice on their birthdays. Menus were available and evidenced that there was always a choice of meal available. At lunch-time those residents who required assistance with eating Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 15 were served their meal a short time before other residents, which enabled them to have assistance as discreetly as possible. High Tea was observed. The tables were attractively set, with fresh tablecloths, and flowers. Residents were able to choose from soup, selection of sandwiches or pate on toast, and a selection of bread and butter, and cake. Staff were noted to be offering assistance in a sensitive and appropriate manner. One resident said “the food is excellent; we have a choice”. Another resident said “my appetite is poor, but I am able to talk with the chef about what I would like to eat”. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a robust system for handling complaints, and this helped ensure that residents were protected and felt that their views were listened to and acted upon. The lack of clarity about the home’s adult protection policy, and correct procedures, could potentially result in residents not being fully protected. EVIDENCE: The system for recording and dealing with complaints was robust. Two complaints had been received by the home since the last inspection, and these were recorded in the complaints log, together with details of the investigation carried out and the outcome of the complaint. One complaint from a Social Worker had been received recently by CSCI in relation to how an adult protection issue had been dealt with by the home; this was partly upheld. The complaint received by CSCI was not recorded in the home’s complaint log. It would be good practice for the home to record any complaints made about the home to other agencies. The inspector was informed that each qualified nurse had received a copy of the Birmingham multi-agency guidelines on adult protection. The home was in the process of reviewing and updating a number of policies and there was lack of clarity about which of two policies on elder abuse was in current use. In discussion with staff they were unclear about who should initiate an Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 17 investigation in the event of any allegation of abuse. It will be necessary for the home to adopt, as a matter of urgency, a policy on adult protection that takes account of Birmingham’s multi-agency guidelines and the Department of Health’s “No Secrets”, and to ensure that all staff are aware of the contents of the policy through training. The home had a policy on Whistleblowing which was comprehensive and easy to read. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided residents with a very pleasant, well maintained and homely environment, which helped ensure that residents were comfortable, secure and generally felt “at home”. EVIDENCE: There had been no changes to the layout of the home since the last inspection. Communal areas within the home were clean, well maintained, tastefully furnished, comfortable and homely. The home was free from malodours at the time of the inspection. A programme of redecoration throughout the home was almost complete, and the floor covering in the dining room had recently been replaced. The home had a lift to the upper floors. During a tour of the home a number of residents’ bedrooms were viewed. The rooms were spacious, comfortably furnished and very homely. Residents had Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 19 been able to personalise their own space to suit their needs and taste, and pictures and fabrics had been used to good effect. The foyer in the home was a spacious, pleasant and comfortable area, with a range of information displayed on boards that were easily accessible. One of the boards contained information, in large print, about quality assurance initiatives within the home. Copies of free local newspapers were available for residents to take. There was also a post-box for outgoing mail and individually named pigeon-holes for residents’ incoming mail. The laundry area was viewed. This was a spacious area and found to be tidy and well organised. Three staff members were employed within the laundry. All equipment was in working order. Clothing worn by residents appeared to have been carefully and appropriately laundered. The home was able to cater for people with impaired or limited mobility, and for wheelchair users. There was a shaft lift for access to each floor and assisted bathing facilities were located on each floor. A staff call system was in place; one member of staff on each floor was designated as “bleep” carrier, enabling a prompt response when a resident summoned help. A range of mobile hoists was available to assist with moving residents. The home had the services of a maintenance operative on one day a week and his duties included keeping the front of the building clear of leaves and debris, and ensuring that the residents patio area was kept clean and tidy. This helped to ensure that residents were able to benefit from a well-kept environment. The home could also call on Bourneville Village Trust’s maintenance staff who were available 24 hours a day, seven days a week throughout the year for any necessary work. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate staffing levels were maintained throughout the 24 hour period to meet the needs of the residents accommodated. Staff morale was high with staff showing enthusiasm about their roles and this resulted in good outcomes for residents. Recruitment procedures were robust, helping to ensure that residents were protected. Staff had good access to training, helping to ensure that they were able to meet the individual needs of residents in a competent manner. EVIDENCE: A number of staff had worked in the home for considerable periods of time, and this was good for the continuity of care of residents. A review of duty rosters and discussions with the nurse in charge evidenced that there were adequate numbers and skill mix of staff on duty throughout the 24 hour period. The personal files of four staff members were sampled and demonstrated robust recruitment practices. Files viewed contained a completed application form, photographic identification, two references (including last employer) evidence of enhanced Criminal Records Bureau checks, and training certificates. The inspector was informed that health declarations are always obtained and that details of these are kept centrally by the Bournville Village Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 21 Trust. There was a system for checking on the periodic registration of nurses with the Nursing and Midwifery Council. Training records were viewed, and evidenced that staff received mandatory training, and that other training relevant to their roles was also available. There was some evidence within staff files that induction was being carried out. The home was in the process of developing an Induction Booklet, covering all aspects of induction over a three month period, for care staff, and the home hoped to implement this in December 2006. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home. The views and opinions of residents were sought and acted upon, helping to ensure that residents felt their voice was heard. Generally the health, safety and welfare of residents was promoted and protected, helping to ensure that they felt safe and secure. EVIDENCE: The home had a general manager, responsible for financial and ancillary functions within the home. The home also had a clinical manager who was qualified in both general and mental health nursing and had substantial experience of working in a care home setting. Although the clinical manager was not on duty on the day of the inspection he attended the home and made himself available for part of the inspection. Both the clinical manager and the Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 23 nurse in charge demonstrated a thorough knowledge of the residents in their care. Feed-back from residents about the care they received was very positive. Relationships within the home appeared to be good, and residents felt confident that if they had any concerns these would be addressed promptly and appropriately. Staff spoken with said they enjoyed working in the home. One member of staff said she felt well supported and had good access to training. A number of individual staff had been assigned to take a special interest in issues such as fire safety and quality, and were enthusiastic about their roles. The home had recently been working with the Bettal “Cared 4” Quality Management system and the quality work appeared to be progressing well. A quality assurance group had been established consisting of staff members and three resident representatives. Questionnaires had been circulated to relatives and to residents/friends, and following analysis of the data, feedback had been made available to all staff and residents. Initiatives introduced as a result of consultation with residents and relatives included the installing of light pull switches above residents beds, and the introduction of two lunch-time sittings in order that residents needing assistance could be given more time and attention by staff. As part of their involvement with the Bettal system the home had been provided with a large number of policies/procedures and was in the process of customizing these for their own use. The home also had a number of their own policies and procedures. At the time of the inspection it was not always clear which policies had been formally adopted by the home, and this was causing some confusion, for example in the area of adult protection. It will be necessary for the home to clarify what policies/procedures are in current use. It will be important for the home to ensure that as new policies are adopted for use and older policies discontinued that there is a clear mechanism for staff to be made aware of the changes. The home’s disciplinary policy was viewed; the policy stated that “suspension will be confirmed in writing and will normally be for no more than five working days which the alleged offence is investigated………..” It is recommended that this be reviewed as the home may not find it possible to complete an investigation within this timescale, particularly in the event of an allegation of abuse where other agencies will be involved. The manager reported that it had proved difficult to arrange staff meetings involving all the staff. Nevertheless, some staff meetings were being held, involving the staff working on each floor, and minutes were available. One member of staff felt that occasional meetings involving all the staff would improve communication within the home. Residents meetings were also held twice a year, with minutes available. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 24 All staff had an individual performance review carried out twice a year. Some supervision of staff was carried out, but this was not always documented. It will be necessary to ensure that care staff receive supervision at least six times a year covering all aspects of practice, the philosophy of care in the home and career development needs, and that records of this are kept. A small number of residents within the home took responsibility for managing their own money. The home was managing the personal allowances of a number of residents. Each resident had his/her own named bank account and monies received were deposited in this account. Some cash was kept in the home for residents day to day expenses. Handling of this was restricted to two members of staff, two signatures were required and receipts obtained for all expenditure. The cash was stored separately for each resident within a locked safe. The administrator carried out a spot check every month to ensure that balances were correct. The home had produced a useful information booklet for residents which outlined and clarified the various aspects of Care Home Fees and this had proved popular with residents. Although staff confirmed that the registered provider visited the home regularly, regulation 26 records were not available in the home at the time of the inspection. An oxygen cylinder for use in an emergency was chained to the wall in one of the clinic rooms, but there was no trolley available. It will be necessary for the home to provide a trolley for the safe transport of oxygen within the home to ensure that it is readily available if required and that staff are not at risk of injury. Various records in relation to health and safety were viewed, and generally found to be up to date. Service records were available for the lift, hoists, nurse call system, fire alarm and water testing for legionella. Copies of accident forms were available. Inspections of residents’ wheel-chairs were carried out weekly by key-workers, and records kept. The home had been inspected by the West Midlands Fire Service in July 2006, and following this the fire officer had written to the home on 5th July 2006 outlining a number of observations for attention. It will be necessary for the home to repeat their fire risk assessment in the light of this inspection and to produce a programme of work, with timescales for completion. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 25 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 2 X 1 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 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 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4(1)(c) Requirement The Registered Manager must ensure that the Statement of Purpose is updated in relation to management changes within the home. The Registered Manager must ensure that the Service User Guide is made available in a language and/or format suitable for intended residents. The Registered Manager must ensure that new residents are admitted to the home only on the basis of a full assessment using a recognised assessment tool. The Registered Manager must ensure that (a) risk assessments are carried out on residents who are being considered for use of bed rails; (b) written consent for use of bedrails is obtained from the resident or his/her representative. The Registered Manager must ensure that care records are fully completed, signed and dated by the person completing them. DS0000024887.V310482.R01.S.doc Timescale for action 01/02/07 2 OP1 5 (1) 01/04/07 3 OP3 14(1) 14/01/07 4 OP8 15 01/02/07 5 OP7 15 14/01/07 Selly Wood House Nursing Home Version 5.2 Page 27 6 OP8 13(1)(b) 7 OP18 12, 13 8 OP18 12.13 9 OP18 12,13 10 OP36 18(2) 11 OP37 10(1), 12 (1)(a)(b) 12 OP38 26 13 OP38 23 (4)(5) 14 OP38 23 The Registered Manager must ensure that records are kept in relation to treatment and advice from any health care professional. The Registered Manager must ensure that an appropriate policy in relation to adult abuse is in place and that staff are aware of its contents. The Registered Manager must ensure that the home’s disciplinary policy is reviewed in relation to suspension of staff from duty. The Registered manager must ensure that staff receive training in the protection of vulnerable adults. The Registered Manager must ensure that staff receive supervision at least six times a year. The Registered Manager must ensure that appropriate policies are in place, that they are regularly reviewed in the light of changing legislation and of good practice advice, and that staff are made aware which policies are currently in use. The registered provider must visit the home at least once a month, unannounced, and prepare a written report on the conduct of the care home. The Registered Manager must ensure that a trolley is provided so that oxygen can be safely transported within the home. The Registered Manager must ensure that the fire risk assessment is repeated in the light of the fire officer’s report, and that a programme of work, with timescales, is implemented. 14/01/07 01/03/07 01/03/07 01/04/07 01/04/07 01/04/07 01/01/07 01/02/07 01/01/07 Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 28 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 OP16 OP9 Good Practice Recommendations The home should record all complaints made in the complaints register. It is recommended that the homely remedies list should be reviewed by the General Practitioner at least once a year. Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Selly Wood House Nursing Home DS0000024887.V310482.R01.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!