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Inspection on 28/11/05 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 28th November 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 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

Most bedrooms have adjustable beds to ensure ease of access for the delivery of personal care. The home enjoys a core of staff who have been employed for an extensive period of time. Permanent or bank staff fill in staffing gaps before an agency is approached. Numerous senior staff are NVQ assessors, which facilitates carers in completing training in NVQ level 2 or 3 qualifications. Strong emphasis is placed upon residents maintaining normal activities of daily living thus ensuring that independence is maintained. The standard of accommodation and delivery of care are consistently good. This was supported by the positive comments received from residents and their relatives.

What has improved since the last inspection?

Bedrooms are redecorated when they become vacant or when deemed necessary. Numerous staff possess NVQ level 3 training, which is a requirement for senior carer status within the home. In the absence of the registered manager an acting manager has been promptly appointed. He is receiving additional support from upper management. The two requirements from the last inspection have been addressed.

What the care home could do better:

The home must ensure that comprehensive care plans are developed in a timely fashion following the admission of a resident. The smaller lounge located on the second floor is underutilised. It is recommended that a review of the usage of small lounges be carried out with the objective of maximising the communal areas for residents and relatives.

CARE HOMES FOR OLDER PEOPLE Selly Wood House Nursing Home Selly Wood Road Bournville Birmingham West Midlands B30 1TJ Lead Inspector Kath Strong Unannounced Inspection 28th November 2005 09:45 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.V269295.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. Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 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 Ms Jean Tandy 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.V269295.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 44 beds of which 24 are for nursing care and 20 for residential care Date of last inspection 29th June 2005 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. Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to carry out the second unannounced inspection of the year. The outcome was determined by a variety of means. The registered manager is currently on long term leave. Discussions were held with the area clinical manager and the area manager who will be taking responsibility for the overseeing of the home on 1st December 2005. The acting deputy manager and the administrator assisted with the inspection process. Four residents and three relatives were spoken with individually. Relevant documentation was examined including four staff files and three care plans, one of which was case tracked in order to ensure that all identified needs were being met. A tour of the premises was carried out and lunch was observed being served. At the conclusion verbal and written feedback was given to the acting manager. This inspection focussed upon the few key standards not assessed at the previous inspection and the two requirements generated from it. Further standards were assessed which formulate an important aspect of the service. In order to gain a full insight into the operations of the home it is advised to read this report in conjunction with the inspection report of 29th June 2005. What the service does well: What has improved since the last inspection? Bedrooms are redecorated when they become vacant or when deemed necessary. Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 6 Numerous staff possess NVQ level 3 training, which is a requirement for senior carer status within the home. In the absence of the registered manager an acting manager has been promptly appointed. He is receiving additional support from upper management. The two requirements from the last inspection have been addressed. 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. Selly Wood House Nursing Home DS0000024887.V269295.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 Selly Wood House Nursing Home DS0000024887.V269295.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): 5 Prospective residents and their relatives are actively encouraged to assess the standard of service provided before making a decision about the home. EVIDENCE: The acting manager advised that enquiries may present via telephone or by unexpected arrival at the home. The home has its own brochure for distribution and a service user guide is issued to those who display a firm interest in the home. Visitors and prospective residents are encouraged to access all communal areas and to talk with residents and staff. They are also invited to sample the food provided. Following admission a three-month trial period is allocated with subsequent review by both parties prior to a placement being confirmed. Standards 1, 2, 3, and 4 were assessed at the last inspection and found to be satisfactory. The home does not provide intermediate care. Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Care plans for new admissions are not completed in a timely fashion and fail to adequately instruct staff in respect of care needs. The involvement of external healthcare professionals is well documented. The arrangements for the administration of medicines were found to be safe. Observations revealed that resident’s privacy and dignity are respected. EVIDENCE: The care plans for residents who have been living at the home for a considerable period of time were found to be comprehensive. The files included physical and mental health needs, risk assessments, health monitoring and the type of care required. Residents and/or their relatives are invited to provide a life history, background, activities of daily living and personal preferences. Both trained and care staff enter recordings, regular and formal six monthly reviews are carried out. The care plan for the latest admission was found to be inadequate. The life history had not been documented or preferred activities of daily living. A medical complication documented three days following admission fails to indicate, action taken, outcome or monitoring. Two known physical illnesses had not been assessed and care planned. The home must complete comprehensive and timely care Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 10 plans. The dedicated page for the recording of elimination requires further development in that the numbering section of the tool must include explanation of the numbering system. An integral element of care plans includes a tool for the recordings of the involvement of external professionals. The files indicated multi-agency involvement. Observations and feedback received from residents indicated that all personal care is carried out in private and that staff treat them with respect. One resident said, “I love it here, staff are very good”. Another commented, “Very nice caring atmosphere, staff are patient and fair with residents who are confused”. The home has completed the new storage arrangements for medications. All aspects of the administration of medications was examined and found to be satisfactory. Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, and 15 In-house and external activities are varied and enrich resident’s social opportunities. Dietary needs are well catered for with a balanced diet and a varied selection of foods that meets resident’s tastes. EVIDENCE: Standards 12, 13 and 14 were examined at the last inspection and were found to be satisfactory with standards 12 and 13 being exceptional. This inspection is no exception, one resident said, “There’s a large range of entertainments which we don’t have to pay for”. Regular outings and shopping trips are continued as well as an interesting in-house activity programme. The home was preparing for the Christmas festivities; the staff of Bournville Trust are presenting a pantomime for the local homes. The meals provided are varied and offer choices for all meals of the day and snacks are available at any time. The main meal of the day is served at lunchtime and the process was observed in the dining room. The layout of the room is of a high standard and permits wheelchair access. The presentation of the meal was very good and resident’s requests regarding portion sizes were complied with. Staff were helpful and discreet and residents were encouraged to take as long as they wished. A resident reported, “We select the day before and the food is good in every way”. Another resident said, “Lovely meals, sometimes we are given a bit too much”. Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Standards 16 and 18 were assessed at the last inspection and found to be satisfactory. Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26 Residents live in a warm, comfortable and safe environment. EVIDENCE: The majority of communal rooms are located on the ground floor. They include a lounge leading on to a spacious well appointed dining room; a small lounge is also available. A further lounge is located on each of the upper floors. The attractive rear garden is accessible from the main lounge and provides seating areas for residents to frequent during clement weather. The Trust has a five year cycle for the redecoration of communal areas, the acting manager advised that the corridors are due to be repainted early next year. There is an ongoing programme of improvements for the fabric of the premises. Communal toilets are situated adjacent to each bedroom and assisted bathing facilities are located on each floor. Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 14 Bedrooms visited were noted to be comfortable and furnished to a high standard. There was an abundance of personal belongings and furniture. Residents expressed their satisfaction with the standard of accommodation provided. The home was found to be warm, tidy and hygienic throughout. Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 15 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): 28 and 29 Recruitment practices are robust in ensuring the protection of residents. Staff receive sufficient training for them to fulfil their roles effectively. EVIDENCE: NVQ training for care staff is actively encouraged and supported within the home with 63 possessing level 2, 37 of which also have achieved level 3 and three staff are currently working towards level 2 accreditation. Three of the seven housekeeping staff have undertaken NVQ level 2 training. Personal files were examined including one of a person who had commenced employment the same day. All relevant checks have been carried out before employment commenced. Standards 27 and 30 were assessed at the last inspection and were found to be satisfactory. Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35 and 38 The acting manager is well supported by the organisations upper management team. The arrangements for the safe keeping of resident’s personal monies are robust. EVIDENCE: The registered manager is currently on long-term leave. A deputy manager has been appointed to oversee the day to day running of the home. Staff appeared to be comfortable with the arrangement and there are clear lines of accountability. Positive interactions were observed, there appeared to be a friendly and relaxed atmosphere and staff responded well to tasks allocated to them by the acting manager. A problem was discussed and the acting manager listened, consulted and asked for suggestions, which were analysed. Verbal information was given regarding the homes commencement of a quality assurance system. Questionaires had been issued to staff and residents and Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 17 the results were being analysed. An audit of food has also been carried out. The home needs to complete the process. All transactions in respect of resident’s personal monies were fully documented with two signatures obtained for each transaction. All aspects of safety were found to be satisfactory. Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 X X 3 Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 19 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 OP7 Regulation 15(1) Requirement Comprehensive care plans must be developed on a timely basis and include all aspects of needs and activities of daily living. Care plan tools must include necessary guidance notes. The home must complete the already commenced implementation of a quality assurance system. Timescale for action 02/12/05 2. 3. OP7 OP33 15(1) 24(1)(2) 31/12/05 28/02/06 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 OP20 Good Practice Recommendations The home should give consideration to ensuring effective use of the lounge situated on the second floor. Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Selly Wood House Nursing Home DS0000024887.V269295.R01.S.doc Version 5.0 Page 21 - 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. 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