CARE HOMES FOR OLDER PEOPLE
Sellywood House Selly Wood Road Bournville Birmingham B30 1TJ Lead Inspector
Kath Strong Un announced 29th 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 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. Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Sellywood House Address Sellywood Road, Bournville, Birmingham B30 1TJ 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) 0121 472 3721 0121 414 0731 Bournville Village Trust Jean Tandy Care Home 44 Category(ies) of Dementia - Over 65 - Old Age (44) registration, with number of places Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 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 14th December 2004 Brief Description of the Service: Sellywood 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 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 are a small parade of shops nearby and bus and rail services are within fairly close proximity. Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The purpose of the visit was to conduct an unannounced inspection; this took place over a period of part of a day. The outcome was determined by a number of means. In depth discussions were held with the registered manager, a group discussion by residents was observed and the inspector spoke with two more residents and two relatives individually. Two trained staff were briefly interviewed. Relevant documentation was examined including four care plans, two of which involved care tracking to determine that all needs were being identified and met. The staffing levels of the home were reviewed. A tour of the premises was also carried out. What the service does well: What has improved since the last inspection?
The home has responded positively and in a timely fashion to the few requirements made at the last inspection. An in depth assessment of the premises had been carried out by an occupational therapist. Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 6 Two members of staff have commenced training in risk assessing, with one working towards a distinction. Several care staff have successfully completed NVQ level three training. Four of the bank staff are doing their nurse training. The staff rota has been reviewed to improve the skill mix for each shift. Pressure relieving equipment has been purchased to increase the available supply. The taps and toilet roll holders have been changed to make them more user friendly for residents and to encourage continuity of independence. The home has purchased two new freezers for the kitchen. New curtains have been obtained and hung in the reception area. The registered manager is now involved in the annual budget setting process for the home. 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. Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 and 4 The homes statement of purpose and service user guide provide sufficient information about the services; enabling an informed decision to be made by prospective residents. Comprehensive pre-admission assessments are carried out for the home to determine its ability to meet the identified needs. EVIDENCE: Historically the statement of purpose and service user guide have supplied all relevant information, no changes had been made to the documents. A copy of the service user guide is issued to all residents. Although the pre-admission assessment tool was determined to be satisfactory at previous inspections the home has made further improvements. The document now has an additional two pages to provide records of individual’s activities of daily living and preferences. This is viewed as being good practice. Prospective residents are encouraged to visit the home along with any other relevant persons and are given the opportunity to sample meals.
Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 9 The home requests that transport is provided for individuals who are hospitalised to give them an opportunity to view the home. Pre-admission assessments are carried out at the home, hospital or the persons own home. The Primary Care Trust (NHS) will be involved in the determination of any nursing needs and continue to participate in subsequent reviews. A trial period of one month is offered prior to a placement being made permanent. Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 There is a clear and consistent care planning process in place, which provides staff with adequate information they need to satisfactorily meet resident’s needs. The home fails to take appropriate action when concerns are raised in respect of resident’s health care. EVIDENCE: The care plans examined included both nursing and residential files. The systems in place for both categories of care were found to be comprehensive and were presented in a logical sequence to facilitate ease of access. Preadmission assessments are included and used as the basis for the more in depth assessment following admission to the home. The documentation includes past and present physical and mental health needs. Relevant risk assessments and regular reviews of all documentation are carried out. Files include self written personal life histories and experiences. Key workers as well as trained staff make entries into the files. Two residents provided positive feedback about their care; one advised, “nurses are very friendly and helpful”. Another reported that his wife received “wonderful care, lots of loving care”, staff take an interest in residents”. Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 11 There was documentary evidence of utilisation of the services of external professionals from a variety of disciplines. Concerns were outlined regarding the failure of trained staff to appropriately monitor a resident who was found to have a lower blood pressure than her previous recordings. Documentation also revealed a resident who had earlier suffered from loss of appetite which was later reported to have improved. However the weight chart indicated a substantial weight loss over a five month period. The home must act upon such findings. Significant improvements were found in respect of the administration of medications; with the exception of storage of medications on the upper floor in a room of an appropriate temperature. The home had identified an alternative room but was awaiting quotations for the installation of security to the window, which may be accessed externally from the roof of the lower ground floor. Advice was given that the work would be completed as soon as possible. Observations during the inspection raised no concerns regarding ensuring the privacy and dignity of residents. Staff displayed respect and provided friendly guidance whilst encouraging residents independence. Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14 The systems of resident consultations are good with evidence that their views are sought and acted upon. The in-house and external activities and links with the community support and enrich resident’s social opportunities. EVIDENCE: As with previous inspections the home has continued to provide an extensive, varied and interesting activities programme. Residents are regularly consulted both individually and via the residents meetings regarding their preferences, resulting in regular reviews of the programme. There are dedicated activities staff employed and the activities notice board revealed an abundance of activities including regular outings. The home also produces and circulates quarterly issues of the ‘Selly Wood Bugle’ and has an annual summer fete. The inspector met with the relative of a previous resident who advised that he visits regularly to “assist with organising of the fete as a way of thanking staff for the care provided to his wife”. The home has a policy of open visiting; one of who reported, “staff make you very welcome”. One of the residents spoken with said “my daughter takes me out in the car every week”. Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a satisfactory complaints system with evidence that residents and relative’s views are listened to and actioned. The home provides a safe environment ensuring that residents are protected from the risks of abuse. EVIDENCE: The home has not received any formal complaints since the last inspection. Historically very few complaints are made. The complaints procedure is issued to relevant persons and is on display within the home. No changes have been made to the written policy regarding adult protection, the document remains comprehensive. Following the last inspection the home has further developed the written procedure in respect of missing persons, which is now satisfactory. The home has a process of ongoing staff training in this aspect of care. Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22, 24 and 26 The standard of the environment in this home is good providing residents with an attractive, comfortable and homely place to live. There is an adequate supply of equipment and adaptations. EVIDENCE: There is a good range of communal areas throughout the home. The ground floor includes the main lounge, dining room and a library/scrabble room. There are smaller lounges situated on each of the upper floors, which are used for specific functions and have the potential for further development. The extensive attractive garden is well laid out, well maintained and includes seating areas. The Trust has a five year cycle of re-decoration of all communal areas. Information was given that the registered manager regularly negotiates with upper management regarding ongoing improvements to the fabric of the premises and the equipment.
Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 15 The home has a good supply of equipment and adaptations including a shaft lift, hoists, hospital beds, grab rails and pressure relieving equipment. An assessment of the home has been carried out by an occupational therapist. The report was found to be very detailed and advise was given that the home is considering some of the recommendations. Bedrooms visited were comfortable and very well appointed. There was an abundance of personal possessions including furniture in evidence. The home was found to be tidy and very hygienic throughout. Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 The staffing complement is acceptable to meet the needs of the current client group. The staff have a good understanding of residents needs, this is evident from the positive relationships between residents and all grades of staff. EVIDENCE: The staffing rota had been reviewed and improvements made which identifies the person in charge on each floor during every shift. The home also provides an early morning shift and twilight shift which increases staffing levels to ensure that residents may rise and retire at their preferred time. This is viewed as good practice. The rolling training programme provided for staff is comprehensive covering all mandatory and refresher training needs. There was evidence of considerable further training, which serves to increase staff knowledge and skills in meeting all of the individual needs of residents. Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 34 The registered manager has extensive experience and skills to carry out her role effectively. There are suitable accounting practices in place for the efficient running of the home. EVIDENCE: The home has a management structure that indicates clear lines of accountability. The registered manager has almost completed a course to gain a diploma in management. The monthly budget sheets and the overall annual budget for the home were seen. The breakdown of the allowances appeared to be satisfactory to meet the running costs of the home. The registered manager has been invited to be involved with the budget setting processes. Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 x
COMPLAINTS AND PROTECTION 3 3 x 3 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x 3 x x x x Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 19 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 OP8 Regulation 12(1)a Requirement The registered person must ensure that appropriate action is taken to make proper provision for the health of residents. The home must complete the work which has already commenced to re-locate the storage of medications on the upper floor. Timescale for action 31st July 2005 30th September 2005 2. OP9 13(2) 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 Sellywood House E54_S24887_SellywoodHseNH_V236306_290605 - Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Birmingham & Solihull Local 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
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