Inspection on 05/07/07 for Showley Brook Care Home

This inspection was carried out on 5th July 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Showley Brook Care Home 28/11/06

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

CARE HOMES FOR OLDER PEOPLE Showley Brook Care Home 10 Knowsley Road Wilpshire Blackburn Lancashire BB1 9PX Lead Inspector Mrs Lynn Mitton Unannounced Inspection 5th July 2007 10:00 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 Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Showley Brook Care Home Address 10 Knowsley Road Wilpshire Blackburn Lancashire BB1 9PX 01254 248188 01254 248188 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) SBC Residential Care Limited Mrs Susan Coupland Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 15 older persons (OP) requiring personal care can be accommodated at the home. 28th November 2006 Date of last inspection Brief Description of the Service: Showley Brook is registered with the Commission to provide accommodation and personal care for 15 older people. It is owned and managed by Susan Coupland. The home is situated in a quiet residential area on the outskirts of Blackburn. There is a church and local shops nearby. Showley Brook is a detached house with gardens to the front, side and rear of the home, which are accessible to residents. There is a small car park with further off-road parking to the front of the building. There are fifteen single bedrooms, one of which is en-suite. Accommodation is on the ground and first floor. A chair lift is available to take residents to and from the first floor. There is a large lounge and a dining room. There are suitable and accessible toilet and bathing facilities. There is a call alarm system. The home is staffed 24 hrs per day. Fees for the cost of a weeks care at Showley Brook ranges from £313.50 £355.00. There was information available to potential residents and their families advising them of the home and giving them details about the type of service they could expect. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted on 5th July 2007. This was the second inspection with the registered person since purchasing the home in July 2006, and it was noted they had worked hard towards improving the homes environment and policies and practices. The registered person completed a pre inspection questionnaire. The inspector spoke to people in receipt of a service, visitors to the home and to the care staff on duty at the time of the inspection. Throughout the report there are references to the “case tracking process”, this is a method whereby the inspector focuses on a small representative group of people using the service. Records regarding these people were inspected. Two people were case tracked, their files examined in detail and two care staff member’s files were also case tracked. Information about the service was received on the Commissions resident’s questionnaire, and relative’s questionnaire. Comments and findings of these surveys are referred to throughout this report. The inspector conducted the inspection with the registered person and senior carer on duty at the time of the inspection. During the inspection a number of records, policies and procedures were also viewed. What the service does well: Assessment documentation was sufficient to ensure the needs of residents could be met upon admission. Personal support was offered in accordance with resident’s wishes, and in a way that promoted privacy dignity and independence. People using the service had opportunities to maintain family links, and they valued this. People using the service were able to exercise choice and control in their day to day living. A programme of planned activities ensured that people had opportunities for their enjoyment, mental and physical stimulation. Aids and equipment met resident’s needs. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 6 Some training had been undertaken to ensure that care staff had the skills to care for people using the service. The attitude of the staff and management was to run the home around the needs and choices of the residents. What has improved since the last inspection? What they could do better: Information about Showley Brook must have all information needed and be suitable for all people using the service. Health and safety staff training and attention to outstanding health and safety issues would ensure the safety of people using the service. 50 of care staff should have achieved NVQ2 qualification so that staff are competent to look after the people in their care. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 7 Patient information leaflets should be in place when using a monitored dosage system, so that staff have information about each drug being dispensed. The visitor’s book should always be completed, for health and safety reasons. The menu should be accurate and reflect the food served. The menu board should have accurate information, i.e. that day’s menu. Ensure that the home is kept free from offensive odours. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP1.OP2, OP3 & OP6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents received information about the service prior to them moving into the home explaining what they could expect, and what was expected of them iif they wanted to live at the home. Assessment documentation was sufficient to ensure the needs of residents could be met upon admission. EVIDENCE: The inspector was shown a newly produced “Residents Guide”. This document had most of the detail needed so that potential new users of the service were well informed. The inspector and registered person discussed the need for the residents guide to be in formats suitable for all potential residents, for example in large print. Two peoples files were examined during the case tracking process. Both had been issued with a contract; this document explained the terms and conditions Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 10 of their stay at Showley Brook, was dated and had been signed by the person using the service. Assessment documentation had been completed for both people prior to their admission. Assessment documentation contained good information to develop a plan of care and meet the person’s needs. Intermediate Care is not offered at Showley Brook. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP7, OP8, OP9 & OP10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s care and health needs were appropriately recorded, ensuring that care staff knew how their needs were to be met. Personal support was offered in accordance with resident’s wishes, and promoted privacy, dignity and independence. EVIDENCE: Two plans of care were examined and these contained good detail, showed residents involvement and had been reviewed recently. They gave staff the information they needed to look after each person. Information about people’s health needs, and how these should be met were also in place. Daily records contained relevant information. The inspector and registered person discussed ensuring that entries are followed up with outcomes, e.g. on one persons records was reference to a GP visit, but no comment about the outcome of this. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 12 A new medication administration system had been introduced since the last inspection. This meant that the administration of people’s medication was now much safer. Controlled drugs were kept securely; the controlled drugs records seen were accurate and up to date. The inspector discussed obtaining patient information leaflets for people’s drugs to be used in conjunction with the new administration system. Homely remedies were given to residents following agreement from there GP. Members of staff administering medication had undertaken training, and had to successfully complete an assessment before they could undertake this task. People using the service told the inspector that some felt they were spoken to and treat with dignity and respect and gave examples of this. The inspector also observed this was the case. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP12, OP13, OP14 & OP15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to exercise choice and control in their day to day living. A programme of planned activities promoted their enjoyment, as well as mental and physical stimulation. Meals were varied and provided a social occasion on a daily basis. EVIDENCE: When asked what the care home did well, one residents family member wrote; “Organising activities to get the residents involved”. When asked if the home helped relatives keep in touch with their family, one residents family member wrote; “Each night they allow my father to ring my mother which I’m very grateful for”. The inspector observed people exercising choice and control over day-to-day elements of their lives, for example, spending time in their room, and getting up at different times. Care staff were seen to respect these choices and opinions. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 14 A weekly activity planner was in place. This included activities such as listening to music, dominoes, bingo, ludo, jigsaws, and old films. Residents spoken to told the inspector that they enjoyed participating in these activities. Resident’s religious needs were met by members of the clergy who visited the home on a monthly basis. The hairdresser was visiting the home at the time of the inspection. The registered person and inspector discussed the suitability of using one resident’s bedroom as the hairdressing salon. Two people go out into the local community of their own accord. Risk assessments were in place. A group of people told the inspector about the ballroom dance they were going to that evening in Bolton and how much they were looking forward to it. One person said; “I love going, and my favourite dance is the square tango, - I really enjoy myself”. Photographs of previous dances were on display in the dining room. The inspector was advised that the Christmas Panto was already arranged and a trip to Blackpool and a BBQ was being planned. Resident’s bedrooms were seen furnished with personal belongings. A number of visitors came to the home on the day of the inspection. The visitors’ book was not always being completed. The inspector noted that a 4 weekly menu was in place. It appeared that this was not being strictly adhered to and had been amended in accordance with resident’s wishes. The inspector advised that the menu be brought up to date. It was noted that the day’s menus were not always being written on the wipe board so that people would know what the day’s menu was. Residents with special needs, for example diabetic and soft diets were catered for. One resident’s relative stayed for lunch on the day of the inspection. Nutritional assessments were seen on care plans case tracked. One resident ate a mainly vegetarian diet. When asked how the care home could improve, one resident’s family member wrote; “The meals are usually good, but my relative does say he could eat more!” Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): OP16 & OP18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures enabled residents and their families to voice any concerns. Alongside these, staff training, helps safeguard residents from abuse. . EVIDENCE: When asked if the care home had responded appropriately to any concerns raised, one residents family member wrote; “I have never had any concerns to raise”. There was a complaints policy and procedure in place, and this was on display in communal areas for residents and their visitors to see. There had been no complaints since the previous inspection. Residents spoken to by the inspector said they were satisfied they would be listened to if they had any concerns or complaints. All staff had received Protection of Vulnerable Adults training during November 2006 and June 2007. A Protection of Vulnerable Adults policy and procedure had been developed since the previous inspection. A copy of the ‘No Secrets’ document and a whistle blowing policy were now in place. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP19 & OP26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general layout and décor of the home provided comfortable and clean surroundings, and was warm, tidy, clean, and mostly free from offensive odours. Aids and adaptations met resident’s needs. EVIDENCE: There was now sufficient moving and handling equipment to meet resident’s needs. The inspector conducted a tour of the building and visited all communal rooms and most bedrooms. The home was clean and homely, and most areas had been redecorated, re furnished and re-carpeted since the last inspection. This included the lounge, dining room and 13 bedrooms. Two residents bedrooms were odorous, this was discussed at the time of the inspection. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 17 The lounge had new curtains, lampshades and pictures/flower decorations. New doors had been fitted to ensure compliance with the fire service. Further maintenance and updating work was taking place the inspector was advised that this might include a new boiler/kitchen and work on the bathrooms. Keypad locks were now fitted on all external and cellar door. The laundry facilities were of industrial standard. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP27, OP28, OP29 & OP30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff on duty reflected the needs of the residents. Recruitment and selection procedures are robust and protect residents from harm. Training undertaken ensured care staff had the skills to care for residents. . EVIDENCE: One resident told the inspector; “the girls are alright – they look after me well”. The staffing rota was seen; this demonstrated that there were sufficient staff members on duty to care for the needs of people using the service. There were usually 3 care staff on duty from 8 am until 1pm and 2 care staff from 1pm until 10 pm. Overnight there was 1 wake and watch and one sleep-in staff. There was a cook employed 35 hours per week. The registered person was included on the rota in order to oversee the day-to-day running of the home. Two staff files were case tracked these demonstrated that staff were being recruited in a way that safeguarded people using the service. Staff contracts and records of training were also seen. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 19 Training records showed that six out of the thirteen care staff had obtained NVQ2, and five were undertaking this training. One member of staff had also completed NVQ 3 and a further 3 were also undertaking NVQ 3 training. Common Induction Standards training was in place for new care staff. Both cooks were undertaking NVQ 2 in catering. The training matrix demonstrated that most staff had completed training, which included - POVA and prevention of abuse, moving and handling, food hygiene, administration of medication, challenging behaviour, fire and evacuation and health and safety. The inspector noted that further training regarding promoting continence had been planned. Records of 1:1 supervisions were seen. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP31, OP33, OP35 & OP38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and staff run the home around the needs and choices of the residents. Residents and regular visitors to the home were consulted about the day-to-day running of the home. EVIDENCE: The registered person purchased Showley Brook in July 2006 and works hands on at the home most days. The registered person has a postgraduate certificate in management. The inspector was advised that effective Quality Assurance and quality monitoring systems had now been developed and implemented. This included Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 21 Investors in People achieved in June 2007. A residents, next of kin, and stakeholders survey had been completed and a staff survey was in the process of being completed. The inspector advised that residents meetings took place every three months and minutes of these were recorded. The inspector was advised that the registered person was not appointee for anyone; and that all other residents’ finances were dealt with by the residents themselves, their next of kin or families. All staff had completed fire safety training in November 2006. Records regarding the prevention of fire, and routine maintenance records of the gas and electrical supplies and appliances such as the stair lift were seen and found to be mostly in good order. The wiring report dated March 2006 stated that the wiring was unsatisfactory. The inspector advised that as the last fire drill was October 2006, one was overdue. Environmental health and the fire service had visited the home since the previous inspection and recommendations made had been or were being implemented. Some health and safety staff training was outstanding, for example, 1st Aid, and infection control and food hygiene for some staff. One member of staff was observed to be moving a resident using and underarm lift. This was discussed with the registered person at the time of the inspection. Risk assessments were in evidence on care plans and these now demonstrated how, once the risk had been identified, the risk was to be managed and what action to be taken in order to minimise that risk. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 22 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 3 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 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 23 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. Standard OP1 Regulation 4, 5 & 6 Schedule 1 Requirement A service user guide must be available and suitable to ensure potential residents know all about the service they may receive. Timescale for action 30/11/07 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 3 4 5 6 Refer to Standard OP9 OP13 OP15 OP26 OP28 OP38 Good Practice Recommendations Patient information leaflets should be in place when using a monitored dosage system. The visitor’s book should always be completed. The menu should be accurate and reflect the food served. The menu board should have accurate information, i.e. that day’s menu. Ensure that the home is kept free from offensive odours. 50 of care staff should have achieved NVQ2 qualification Health and safety staff training and attention to outstanding health and safety issues should be arranged and complied with. Showley Brook Care Home DS0000067068.V339483.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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