CARE HOMES FOR OLDER PEOPLE
Shirwin Court 46 Poplar Avenue Edgbaston Birmingham West Midlands B17 8ES Lead Inspector
Jill Brown Announced Inspection 23rd November 2005 09:40 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 Shirwin Court DS0000017022.V259916.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. Shirwin Court DS0000017022.V259916.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Shirwin Court Address 46 Poplar Avenue Edgbaston Birmingham West Midlands B17 8ES 0121 420 2398 0121 686 3727 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) Mr Rahmatullah Hissaund Mrs Bibi Hissaund Mr Rahmatullah Hissaund Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Shirwin Court DS0000017022.V259916.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19 May 2005 Brief Description of the Service: Shirwin Court is a privately owned double fronted property that is laid out three floors. The home offers accommodation for 10 older people. The home is situated 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 stair lifts 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 en suite 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 DS0000017022.V259916.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The announced inspection took place over 5 hours on a day in November. Two resident case files and 2 staff files were looked at. Medication administration and the maintenance and inspection of some services such as gas and electric were checked. The inspector joined the residents for the main meal of the day. Three residents were spoken with. In addition, the home completed a pre inspection questionnaire and the Commission received 5 comment cards; 2 from residents of the home and 3 from relatives. The Commission is undertaking reduced inspection processes and not all of the standards have been inspected. It is advised that this inspection report is read with the previous inspection report of the visit in May of this year. What the service does well:
The home has clear assessment processes and the assessments of residents are reviewed every six months at which point changes in resident’s condition can clearly be seen. The assessments clearly link to the care plans written for residents. Care plans describe how care should be given to residents and are personalised to each resident such as … ‘explain what you intend to do’ and ‘likes to read the Mirror.’ Care plans were reviewed monthly. The assessment and care planning processes ensured that residents were cared for consistently and well. The home works well to ensure that resident’s health needs are met and health professionals are contacted if the need arises. Residents and relatives were very happy with the care provided in the home. One resident said ‘it was like Christmas every day at the home’. It was clear that the home adapted their service to the needs of the residents. A number of residents spend time in their rooms enjoying their televisions, painting, doing crosswords and others stayed in the lounges watching television, playing dominoes, or reading. Residents spoken to enjoyed the meals, arrangements were made for residents who preferred different types of food. The menus provided nutritious English traditional food suitable for the current population of residents. The homes arrangements for receiving complaints and dealing with them, and their procedures for protecting residents were good.
Shirwin Court DS0000017022.V259916.R01.S.doc Version 5.0 Page 6 The home was clean and fresh and offered a homely environment for residents. The arrangements for staffing the home were good with many staff achieving the required standard of training. The management of the maintenance of the building services such as gas and electric supplies, servicing of the lifting equipment and so on was good. What has improved since the last inspection? 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. Shirwin Court DS0000017022.V259916.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 Shirwin Court DS0000017022.V259916.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): 1, 3 The information collected on residents enable the home to decide whether they could meet the resident’s needs. This helps to ensure that residents do not have to move quickly to another placement. EVIDENCE: The home had an updated version of its statement of purpose and a copy of this must be sent to the Commission. Assessments were undertaken prior to residents being admitted. One of the owners of the home assessed residents and if needed would attend a hospital to do this. The home reassesses residents on a six monthly basis. The records clearly demonstrate where a resident’s health has deteriorated. The assessment covers all the areas required by the standard. No new residents had been admitted since the last inspection. Shirwin Court DS0000017022.V259916.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, 10 The arrangements for the care planning and meeting health needs of residents were good keeping residents as well as possible. Some improvements on the administration of medication were needed to ensure the safety of residents. EVIDENCE: The care plans that are produced reflect the highlighted areas of concern in the assessment information. Care plans also had personalised information that were important to ensure that residents feel cared for such as ‘likes to see the garden and the birds, reads the Mirror newspaper.’ Care plans also had directions to staff on how care was to be delivered for example ‘explain what you intend to do’ (before giving care) ‘praise any effort made’ (by the resident). Care plans were reviewed monthly and there were occasions where the care plan had been updated as a result. Residents’ health appeared well attended to. Residents had access to GPs, district nurses, opticians, and chiropody and so on when needed. The residents had been free from accidents and falls since the last inspection. One resident said ‘they look after me well and I like to be independent but sometimes I get dizzy. As soon as I stand up someone is there to help me.’
Shirwin Court DS0000017022.V259916.R01.S.doc Version 5.0 Page 10 The home’s arrangements for administration of medication needed some improvement. One resident that recently had become allergic to medication had this written on case records and the medication administration record (MAR). This addition to records should be dated to ensure that this can be found if needed. One change to the frequency of medication was not signed for and was contrary to the prescription as one dose was being given as required during the day. This must be agreed with the GP and written up in the care notes. A more robust way of auditing this medication was needed so at any point the number of tablets in the home could be accounted for. The copy of the prescription should be kept with the relevant MAR so they can be archived together and a check can be given before each administration. One resident had recently become allergic to a medication and records of this must be dated. Residents spoke highly of the owners that provide most of the care to residents. It was clear residents had their own clothes and belongings around them. Residents were spoken to in a respectful manner and a number of comment cards spoke of the home as being a family. Shirwin Court DS0000017022.V259916.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, 14, 15 The arrangements for activities, meals and choice were individually based and these arrangements enhance residents’ lives. EVIDENCE: Residents were getting ready for Christmas and a number of residents were getting involved in dressing a Christmas tree. One resident said ‘Its like Christmas here everyday.’ One resident decided to entertain the others by dressing up as a Christmas tree. There was a lot of singing during the inspection visit. A number of residents have time in their own rooms watching their televisions, doing artwork or crosswords. Some residents spend time in the communal area doing these types of activities. Activities residents enjoy were recorded in their assessments and care plans and residents were seen to be enjoying those activities. Residents thought they had choice within the home and their routines reflected the way they liked to live. Residents thought the food provided was good. It was clear that residents that had long standing patterns of eating had their needs and wishes accommodated by the home. On the day of the inspection the inspector joined residents for the main meal of lamb potatoes and three vegetables this was well cooked and enjoyed by the residents that chose this. As this is a small
Shirwin Court DS0000017022.V259916.R01.S.doc Version 5.0 Page 12 home the home does not operate a formal choice but will offer alternatives if needed. The menus appeared balanced, offering traditional English food with cooked breakfasts at least three times a week. This was acceptable for the resident population. Shirwin Court DS0000017022.V259916.R01.S.doc Version 5.0 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 the following standard(s): 16, 18 The homes complaint procedures and practice ensure that residents remain safe. EVIDENCE: The home and the Commission have received no complaints about the service the home offers in the last year. Comment cards showed that residents were happy with the service. Residents said that they would be able to complain to the owners if they were unhappy. One resident was able to talk of a time in the past when they were unhappy and said the owners dealt with the problem very swiftly. The home has adult protection procedures in place and these clearly state that the owners are to be informed and that consultation must be had with the Commission and the agency funding the resident’s placement. Shirwin Court DS0000017022.V259916.R01.S.doc Version 5.0 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 the following standard(s): 26 The home was clean and fresh. Some improvements had been made and these enhance the environment for residents. EVIDENCE: The environmental tour of the home did not take place at this inspection however a number of previous requirements made of the home were checked. The homes lounge had been redecorated, more electrical sockets had been provided in bedrooms to reduce the need for electrical extension and socket leads and a showerhead had been provided for the bath. Not all bedrooms were looked at and the previous requirement about the decoration of bedrooms was brought forward. The areas seen by the inspector were clean and fresh. The home has not provided a sluice washing machine, as a replacement has not been needed. Shirwin Court DS0000017022.V259916.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): 27, 28, 29, 30 The arrangements for staffing the home were good with many staff achieving the required standard of training. Arrangements for recruiting staff and giving existing staff updates on mandatory courses needed to be improved to ensure the continued safety of residents. EVIDENCE: The homeowners provided a substantial amount of the staff hours in the home. A long-standing staff group provided the rest of the hours. The home had eight residents in the home at the time of the inspection and the staffing levels appeared appropriate. The home reported that 50 of the homes staff have achieved the NVQ2 in care. Staff had the required checks before being employed one staff member had a Criminal Record Bureau check from another organisation and this must be up dated. Staff had some updated training but not completely covering the mandatory training required and this could cause potential risks to residents. Shirwin Court DS0000017022.V259916.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): 33, 35, 36, 38 The management of the home was good but some work on continuing improvement and risk assessment was needed to ensure the service remains safe and improves the lives of residents. EVIDENCE: The home had yet to implement a method of quality assurance. The management of residents’ money was good with the homes records being consistent with the amount of money held. Receipts of individual spending were kept. The home needed to ensure that the record of property held in the home was clear and not open to interpretation. Staff were receiving supervision on a routine basis and this appeared appropriate. Shirwin Court DS0000017022.V259916.R01.S.doc Version 5.0 Page 17 The home had appropriate maintenance and inspection records of services such as gas and electric. Fire safety records showed that a drill was undertaken on a routine basis, testing was done on the fire alarm and emergency lighting as required. The homes Fire risk assessment was not thorough and a new format was needed. Shirwin Court DS0000017022.V259916.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 2 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 2 3 X 2 Shirwin Court DS0000017022.V259916.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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. 2. Standard OP1 OP9 Regulation 4(1) 13(2) Requirement A copy of the homes updated statement of purpose must be sent to the Commission. Medication must be given as prescribed unless changed by the prescriber. If this is the case the home must maintain a record of this. The home must ensure that the system of medication allows a quick method of auditing. The Registered Person must ensure that all bedrooms are decorated to a reasonable standard. (This requirement was not inspected on this occasion.) The registered person must be mindful of the need to provide a sluice washing machine to meet the needs of the residents. (This part of the standard was not assessed on this occasion and was brought forward.) The Registered Person must ensure that there are temperature records for both freezers. (This requirement was not
DS0000017022.V259916.R01.S.doc Timescale for action 31/01/06 31/12/05 3. 4. OP9 OP24 13(2) 23(2)(d) 31/12/05 31/03/06 5. OP26 23(2)(k) 30/06/06 6 OP26 13(3) 31/01/06 Shirwin Court Version 5.0 Page 20 7 8 9 OP29 OP30 OP33 19 17(2) 4 (6) 24 10 11 OP35 OP38 Sch4(9)a 13(4)(6) inspected and was brought forward.) All staff must have a Criminal Records Bureau check for their employment at the home. The Registered Person must ensure that staff complete the mandatory updates on training The Registered Person must ensure that systems are in place to review and improve the service provided. (This requirement was outstanding from the last inspection.) The home must ensure the records of valuables are accurate. The Registered Person must ensure there is a fire risk assessment and that routine monitoring is against a list of what has been checked. 31/01/06 31/03/06 31/03/06 31/12/05 31/01/06 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 2 Refer to Standard OP9 OP9 Good Practice Recommendations It is recommended that the home date any records where a resident has become allergic to a medication. It is recommended that the photocopy of the prescription be kept next to the medication administration record that it relates as an added check. Shirwin Court DS0000017022.V259916.R01.S.doc Version 5.0 Page 21 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 Shirwin Court DS0000017022.V259916.R01.S.doc Version 5.0 Page 22 - 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!
