Inspection on 19/05/05 for Shirwin Court

This inspection was carried out on 19th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Shirwin Court 13/07/07

Shirwin Court 21/09/06

Shirwin Court 23/11/05

Shirwin Court 21/09/04

Shirwin Court 19/04/04

Shirwin Court 02/03/04

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Bank House

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

CARE HOMES FOR OLDER PEOPLE Shirwin Court 46 Poplar Avenue Edgbaston Birmingham B17 8ES Lead Inspector Jill Brown Unannounced 19 May 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. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Shirwin Court Address 46 Poplar Avenue Edgbaston Birmingham B17 8ES 0121 420 2398 0121 686 3727 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) Mr R Hissaund Mr R Hissaund Care Home 10 Category(ies) of Old Age (10) registration, with number of places Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21 September 2004 Brief Description of the Service: Shirwin Court is a privately owned double fronted property property that is laid out three floors. The home offers accommodation for 10 older people. The home is stuated in Edgbaston close to the hagley road. From there is public transport available to the centre of Birmingham. Shops and other amenities are available within walking distance to Bearwood shopping area. The home has 6 single and 2 double bedrooms that are located on all three floors. There are stairlifts between each floor. The top flight of stairs is steep and narrow and can only be negotiated by mobile residents. Communal toilet and bathing facilities are available on the ground and first floors. The second floor bedrooms have toilets but the ensuite showers are not useable as they cannot be restricted to 43 degrees Centigrade. One of the bathrooms has a hoist for assisted bathing. Not all toilets are large enough for staff to offer assistance. The home has a large well furnished lounge that overlooks a pleasant garden with shrubs, patio and garden furniture. The separate dining room is used by residents for activities as well as for meals. The home has a ramp and handrails to the front door. Parking is only available on the road. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited unannounced on a day in May. Three residents’ case records were inspected. The inspector toured most areas of the building and looked at maintenance and fire records. Five residents, the manager and deputy were spoken to. There were 8 older people resident at the time of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The registered person must improve on future planning rather than relying and responding to inspection requirements. Routine decoration and maintenance and responding to likely residents needs must be part of this. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 Page 6 The home has to ensure that all risks in an emergency are considered and have ways of dealing with them including access to fire escapes on the first and second floor. The development of a clear quality assurance system would enable the home to plan for future resident needs and wishes as well as improving the service the home offers. 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. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 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 Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 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) 3 Residents’ needs are assessed prior to admission to the home and these needs are kept under review. These arrangements ensure that residents’ needs can be met. EVIDENCE: The residents’ files had admission information and there was evidence of the home’s assessment. Assessments were routinely updated six monthly and this is good practice. Risk assessments were undertaken for perceived risks such as smoking and actions to minimise these risks were shown in the residents’ care plans. Potential residents are assessed by the owner either in their home or in the hospital prior to admission. One resident said that he’d be in the home for two years and that his admission to the home was a good decision. The statement of purpose was not viewed on this occasion and the requirement made at the previous inspection was brought forward. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 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 standard(s) 7, 8 Care plans were in place and had appropriate level of detail to ensure that residents’ needs were met. Residents’ health care needs were met. EVIDENCE: Residents’ care plans had good detail such as clear assistance to mobility instructions and care to be given. The assessment and care plan are reviewed monthly. Residents spoken to said that they were happy in the home. One resident said that he had improved in health in the last three years and was happy to have put on weight. Residents had access to hairdressing, chiropody, eye tests, dentists and doctors when required and routinely. Residents did not fall and there were no accidents recorded in the home. No residents have pressure areas or sores and a resident that is at risk of developing pressure areas has been supplied with a pressure-relieving mattress. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 Page 10 Medication administration was not viewed on this occasion and requirements made for staff to receive training and to improve administration of medication was brought forward. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 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 standard(s) 12, 13 Residents had a range of both communal and individual activities to keep themselves occupied. These arrangements along with those to have visitors was adequate to meet their needs and wishes. EVIDENCE: Three residents were involved in playing a game of dominoes during the inspection. The other residents were spoken to. They said that they felt able to be involved in activities in the home but many enjoyed reading. One resident said that the staff brought him crosswords cut out of the newspaper and that kept him busy. Those residents that wanted were able to involve themselves in assisting in tasks within the home. One said that he had a box of paints in his room if he wanted to paint and that occasionally he goes out with the owner to the shops. The home has a television in both the lounge and the dining area and some residents have them in their bedrooms. Review notes written by a social worker stated the home has good social interactions with the residents. Residents were able to have visitors and there appeared to be no undue restrictions on this. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 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 standard(s) These standards were not inspected on this occasion. EVIDENCE: Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 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 standard(s) 19,20,21,23,24,26 The environment standards and arrangements for the upkeep and maintenance of the home was variable. Some aspects of the home’s environment failed to meet all residents needs. EVIDENCE: The home was reasonably well maintained throughout. Some routine redecoration needed to be undertaken in some bedrooms and the lounge. The home had recently refurbished the kitchen with new storage units and theseappeared to be of a high standard. Freezer temperatures were not inspected and this requirement was brought forward. The garden was well landscaped had garden furniture and could be viewed from the main lounge. The home has adequate space in the communal areas for the residents. An assisted bathing facility is available on the first floor but this did not have a showerhead facility to wash residents hair. The toilet facilities on the ground floor are small and not appropriate for residents that require assistance. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 Page 14 The bedrooms were well furnished with good storage facilities. Bedrooms do not provide the amount of electrical sockets recommended the home have provided extension leads with extra sockets and these must be included in a building and fire risk assessment. The home must consider the provision of additional sockets in order to meet residents’ needs and wishes and minimise the risk of accidents. Liquid hand wash soap and paper hand drying facilities were available throughout the home. Hot water outlets, where tested, were appropriately restricted in temperature. The home does not have a sluice washing machine; the home must be mindful of this when admitting residents and future purchases. The home was homely and fresh throughout. The home has made some improvements since the last inspection but need to ensure that routine redecoration is planned for to ensure that resident’s living accommodation remains comfortable. The home was clean and pleasant but needs to ensure that it plans for the future hygiene needs of residents so that infections to residents can be minimised. Fire exits are through a resident’s bedroom on second floor and through bathroom on first floor and these facilities fail to fully respect the residents right to privacy. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 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 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 The residents’ needs were met by appropriately trained staff. EVIDENCE: The staff on duty on this occasion were the owner and his wife which was appropriate for the 8 residents at the home. The staff rota showed that these levels were kept throughout the week. The staff files were not inspected and the requirement to have evidence of training was brought forward. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 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 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) 31,33,37,& 38 The home has well qualified management and health and welfare of residents was safe guarded by adherence to maintenance and inspection of services. The registered person needs to ensure quality assurance systems are in place to that the home improves in the way residents wish. EVIDENCE: The owner and care manager of the home has almost completed the Registered Managers Award and is a qualified as a Registered Mental Nurse (RMN). The home ‘s deputy has completed the RMA and is awaiting the certificate. The home had developed a questionnaire for new residents to give their initial impression of the home. The home did not have an independent Quality Assurance audit and did not have a system of collecting together views and opinions across the whole service to inform development in the home. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 Page 17 The home had a small office where information and records were kept securely. The home kept records in an orderly fashion and information was easy to retrieve. Fire records were all in place including the home’s own testing and maintenance records. The home had a fire drill recently. The home had a fire risk assessment and this had been reviewed in April this year this should take into issues reported in standard 24 and 21. The five-year wiring, landlords gas certificates and the testing of electrical appliances were all in place. The home has the appropriate Legionella test certificates in place. Rooms were inspected for and health and safety risks but not against a checklist. Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 2 2 x x 2 2 2 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x 1 x x x 3 2 Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 Page 19 NO 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 op1 Regulation 4(1) Requirement The Registered Person must ensure that the statement of purpose includes all the information required by schedule 1 of the Care Homes Regulations and pass a copy to the CSCI. (This standard was not inspected on this occasion and this requirement was brought forward.) The Registered Person must ensure that no more than one service users medicines are decanted in to a tot at any time. The Registered Person must ensure that there is a copy of the prescription to check the received medicines against. A record must be maintained on the Medication Administration Record(MAR) when creams have been applied. All staff handling medicines must undertake accredited training in the safe handling of medicines. (These requirements were not inspected on this occasion and Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 Page 20 Timescale for action For the next inspection. 2. op9 13(2) 15/07/05 3. op18 13(6) 4. 5. 6. op20 op21 op24 23(2)(d) 23(2)(n) 13(4)(c ) these have been brought forward.) The Registered Person must ensure that all relevant details are included in the adult protection policy. ( This standard was not assessed on this occasionand this requirement was brought forward.) The homes lounge must be redecorated. The home must provide a shower head to enable staff to wash residents hair. The building and fire risk assessment must reflect the exits through the bedroom and bathroom and the use of electrical extension leads. The Registered Person must ensure that all bedrooms are decorated to a reasonable standard. ( the latter requirement was outstanding since the 01/12/04) The registered person must be mindful of the need to provide a sluice washing machine to meet the needs of the residents. The Registered Person must ensure that there are temperature records for both freezers. (this regulation was not inspected and the requirement was brought forward.) The Registered Person must ensure that evidence of training undertaken by staff is maintained on the staff files. ( this regulation was not inspected on this occasion and is brought forward.) The Registered Person must ensure that systems are in place to review and improve the 31/07/05 31/08/05 30/06/05 30/06/05 7. op26 23(2)(k) 31/03/06 30/06/05 8. op30 17(2) schedule 4 (6) 30/06/05 9. op33 24 31/08/05 Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 Page 21 service provided. 10. op38 13(4)(6) The Registered Person must ensure there is a building risk assessment and that routine monitoring is against a list of what has been checked. 30/06/05 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 op22 Good Practice Recommendations The registered person must carry out a risk assessment to show how a service user that became be immobile would be brought downstairs in an emergency situation. ( this remains outstanding since the last inspection.) It is recommended that the home has two double sockets available for each bedroom. 2. op25 Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 Shirwin Court E54 S17022 Shirwin Court V228639 190505 Stage 4.doc Version 1.30 Page 23 - 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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