Inspection on 04/01/08 for Silver Birches

This inspection was carried out on 4th January 2008.

CSCI found this care home to be providing an Adequate service.

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

Silver Birches 19/02/09

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Silver Birches 85 Lutterworth Road Aylestone Leicester LE2 8PJ Lead Inspector Keith Charlton Unannounced Inspection 09:30 4 January 2008 th 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 Silver Birches DS0000070953.V355332.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. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Silver Birches Address 85 Lutterworth Road Aylestone Leicester LE2 8PJ 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) 0116 2832018 Pine View Care Homes Ltd Post Vacant Care Home 16 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (16) of places Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To residents of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE(E) Old Age, not falling into any other category - Code OP 2. The maximum number of residents who can be accommodated is: 16 Date of last inspection This is a newly registered service. Brief Description of the Service: Silver Birches care home provides care and accommodation for up to sixteen older people or older people who have dementia. It is set in Aylestone about four miles from the city of Leicester where residents have access to a variety of shops and other facilities. There is easy access for private and public transport. The premise consists of two floors and residents have access to both floors with the use of the passenger lift or stairs. There are a variety of aids and adaptations in the home to assist residents. There are twelve single bedrooms six with en-suite facilities with two double bedrooms with en-suite facilities. There are sufficient toilet and bathroom facilities on both floors based on sixteen people residing in the home. The home has a garden to the rear of the premises. The weekly fees range from £ 330 to £ 400 per week - the Registered Provider provided this information on the day of the inspection. There are additional costs for expenditure such as hairdressing, private chiropody, toiletries, and newspapers. A Service Users Guide to the services the home offers can be supplied to applicants and the Statement of Purpose is displayed in the hallway. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Registered Provider and Acting Manager were on duty. Planning for the Inspection included checking on the notifications of significant events sent to the Commission for Social Care Inspection, reading an anonymous complaint and the Registration Report for the current Registered Provider who bought the home in October 2007. The Inspection took place between 09.30 and 15.30. The inspection included a tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with seven residents (though this was limited owing to the difficulty with communicating with some residents with a high level of mental frailty), two members of staff, two relatives, the Registered Provider and the Acting Manager. The Inspection was completed on the 8th January 2008. Surveys have been returned by a relative and two staff, which contained critical comments regarding lack of staff and activities and continence programmes not being in place. These are explained in the Report. What the service does well: There were a number of issues which covered residents needs – residents spoken to were generally satisfied with the care they received from staff and management and they thought that the food was good in general. The inspector also observed that staff were friendly and helpful in their dealings with residents, visitors are made welcome and relatives can assist in the personal care of their relatives, and residents feel that the management Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 6 will act on any issue they raise. The inspector also found that the Acting Manager was very keen to put good practice issues in place. Residents needs are actively promoted. Staff were aware of how to promote residents independence and this was reflected in their Care Plans. Residents are asked in Residents Meetings as to their preferred activities. Residents said that there were no rules so they could choose how they live their lives. Bedrooms were personalised with residents stating they were happy with them and they could bring in their personal possessions. The Registered Provider had only taken over the home less than three months from this inspection but had recognised that improvements to facilities were needed and had taken steps to put these into place. Ongoing work was seen to be occurring to ensure facilities are raised to a good standard. Staff training is encouraged so that staff carry out most essential training and are encouraged to undertake National Vocational Qualification training on care skills. Staff are asked to read residents Care Plans and the Policies and Procedures of the home so that they know what to do and are consistent in their work. Staff members spoken to were aware of the fire procedure and how to protect residents from abuse. What has improved since the last inspection? What they could do better: Residents needs would be more effectively covered by ensuring that: Any changes in need are identified and subsequently how support is given then the care plans should be reviewed at least monthly, some improvements to medicine management are necessary, to ensure the safety of residents. Management need to ensure residents are always spoken to with respect, that the activities provided include more variety and frequency of outings, that there is a set choice of food at the main meal, that facilities are always kept clean and tidy with no malodours and to ensure that facilities are fully Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 7 upgraded to improve the homeliness of the home, to fully cover domestic tasks, to ensure that staff shifts have sufficient staff on duty to cover all residents needs, to extend the training programme to include some more relevant issues regarding residents care so that staff to have knowledge of residents conditions. There needs to be a Registered Manager in place in the short term to ensure consistency of care and management. All health and safety systems in the home need to be regularly monitored and tested to ensure residents safety at all times. 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. Silver Birches DS0000070953.V355332.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 Silver Birches DS0000070953.V355332.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): 3,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission process is managed and meets the general needs of residents. EVIDENCE: Some residents said that staff visited them before their admission into the home and talked about their care needs and they could visit the home prior to their admission. The Inspector looked at residents files, which contained information in terms of medical, physical and social needs of residents. The Acting Manager was asked to adapt the assessment form to include medical checks – last optical and dental checks, whether there is a need to refer to medical services regarding hearing tests, continence etc. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 10 The Registered Provider does not provide intermediate care. Silver Birches DS0000070953.V355332.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): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans identify most care needs but are not fully comprehensive. Residents health needs are monitored and acted upon. Effective medication systems are generally in place. EVIDENCE: Care plans inspected were found to contain relevant information regarding residents needs. Relatives said that they were aware of Care Plans and one relative said she had looked in detail and thought that it covered the needs of her mother. Some areas of need are not specific enough – e.g. there was no evidence of referrals to Medical Services or toileting plans for residents with continence Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 12 difficulties or the last appointments regarding medical checks for the optician and dentist. There were comments contained in a relative’s survey regarding staffing levels being inadequate to meet residents needs at night when there is only one Care Assistant on duty, stating that toileting is not carried out in the afternoon as per this resident’s Care Plan and the pad not changed at night, thus increasing the vulnerability to pressure sores. The Registered Provider said that he was currently updating the plans and they would be fully in place as soon as possible. They need to be discussed with the resident/representative to ensure they are appropriate to the care needs of residents. All of the residents spoken with confirmed that when they feel unwell a doctor is called out to see them. There are also risk assessments in place accompanying care plans and appointment records that show specialist healthcare professionals are involved in residents’ care - there was information regarding residents appointments with medical services – the GP etc. One staff survey stated that ‘residents have not been assessed ….by the District Nurse for their incontinence needs….this means that some residents are constantly wet and vulnerable to pressure sores’. A relative also stated that her mother was not being properly toileted during the day and night. The staff survey goes on to state that when the Care Plan states that two staff are needed to safely move and handle residents then only one staff is allowed to do it, that meal times are rushed and two residents who cannot feed themselves do not get enough food to eat as there are not enough staff on duty to properly feed them, and that there are no activities and little staff communication with residents. These issues need to be followed up by the Acting Manager and Registered Provider and a response given to the Commission for Social Care Inspection. It was also recommended that the personal history section is completed to ensure residents are seen as individuals with a valued past. The Acting Manager said this information could be supplied from relatives and would be followed up. Staff said they had been asked to read Care Plans by the Acting Manager, which helps to ensure that all relevant information is available for staff to meet residents needs. Monthly reviews of plans need to be carried out on Plans to ensure they were still relevant to residents needs. Accident records were viewed and it was found that incidents had been properly followed up with medical services where necessary. There was one incident regarding staff applying a dressing to a resident following a fall where Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 13 the inspector asked the Acting Manager to discuss the procedure of staff being able to do this. A medication round was observed over lunchtime. The staff member dispensed medicines made sure that residents had taken it with a drink, though had already signed the medication administration record. This is not safe practice because the residents may not take it. Medicine records were found to be generally up to date. There were only a small number of gaps records and medication not supplied on the relevant day. The Acting Manager said these issues would be followed up. Staff members said they were not allowed to give medication without having received medication training and this was a comprehensive twelve week course. Medication is kept in a locked and secured trolley. Staff were observed to be talking to the residents with respect and friendliness. Some residents said that staff raised their voices sometimes. This was also noted in residents meeting notes in November 2007. The Acting Manager said this would be taken up and monitored, as it was not acceptable practice. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to have a stimulating lifestyle though this needs to be extended. EVIDENCE: Residents said that there were activities but they did not think they were too frequent and they liked staff to spend time with them, talking and singing with them but this was not often as staff were busy . The inspector did not observe any activities taking place though staff described what was available – exercise once a fortnight, board games and bingo. There were some comments that residents would like to be taken out for walks and outings. Surveys received from residents and a staff member said that there are ‘sometimes’ activities arranged by the home that residents could take part in, with comments that there should be more activities organised to keep residents stimulated. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 15 It was discussed that residents be consulted again over what activities they would like to do and that an Activities Programme is set up. The Registered Provider said that said this would be looked into and that he agreed with the inspector recommendation that staff will be trained in providing activities for residents with dementia. The vicar visits on a monthly basis to give a service and to chat with residents. Some residents wanted to have communion as well – the Acting Manager said she would look into this. Residents spoken with confirmed they still have control over their lives. For example, they can get up and go to bed when they wish and spend their time as they please, either in the company of others or on their own. A resident was observed being in bed late in the morning, as he chose. Staff indicated that there were no rules in general and there was free choice regarding residents getting up and going to bed times. One resident was seen to have a restriction placed on him regarding alcohol, though this had not been assessed in his Care Plan or discussed with him, as per the Requirements of the Mental Capacity Act. The Registered Provider said this would be followed up. Residents Meetings have been organised though because a large proportion of residents have dementia and find it difficult to communicate the inspector recommended that joint residents/relatives meetings be set up to inform management as to suggestions/quality of life issues for residents. The inspector recommended that residents be given the opportunity to be represented in staff and management meetings and staff recruitment. The Registered Provider said these issues would be looked into. It is also recommended that memory boxes, containing valued items, be set up for residents, so as to provide valuable reminiscence material for residents with dementia. Relatives confirmed that they are made welcome by staff and can take residents out if they wish. Relatives said that they were glad they are given the choice of being able to take part in the personal care of their relative and that staff inform them if their relative was not feeling well. Daily records indicate that residents see their families regularly. A number of residents said they enjoyed the home’s food. There was a comment that food could be cold at times. A survey received from a resident said that the resident ‘usually’ liked the meals the home provided. The Acting Manager said the food would be monitored. Menus indicated that an alternative is available if wanted though there is no set choice of main meal, which the Registered Provider was recommended to Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 16 provide, as per the National Minimum Standard. There are choices for the breakfast and tea menu. Records showed what breakfast and tea choices are offered and what vegetables are served. It is recommended that a menu board be displayed to supply information to residents. Residents were seen to be receiving assistance from staff to eat food and residents weights are to be monitored on a regular basis. The food tasted was found to be of a generally good standard with flavour. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 17 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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current system protects residents from the possibility of abuse. EVIDENCE: Residents said that they did not need to complain but if they did they thought the Manager would look into it properly if they ever needed to. A comment in a staff survey stated that some residents are unwilling to comment regarding concerns due to repercussions though did not give further information or examples of this. Nevertheless, it needs to be followed up by management. The Complaints file was viewed where there were no complaints recorded since the Registered Provider took over. However there have been a small number of complaints made, which the Registered Provider/ Acting Manager is to record so that issues can be seen to have been properly followed up. There is a Complaints Procedure, which now needs to include the local Social Service Department as the lead agency for investigating complaints and to Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 18 state that the complainant has the choice of going to the Social Service Department first, not the home, if they do not wish to. The Registered Provider said this would be changed. Staff members were asked about their understanding of the adult protection procedures, and demonstrated a generally good understanding of these. The Complaints Procedure was displayed in the home where it is accessible to residents and their relatives. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 19 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): 19,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in an environment that they generally think is satisfactory, though standards of cleanliness and décor and furnishings need to be improved. EVIDENCE: Residents said that they liked their bedrooms and the inspector observed that bedrooms were generally satisfactory and contained personal possessions – pictures, photos, ornaments etc. The Registered Provider said that he had recognised that the facilities of the home were generally run down and plans were already in place to refurbish the home in the short term, as major redecoration was needed plus the Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 20 replacement of worn furniture and carpets. The inspector saw this was in hand with a bathroom being refurbished at the time of the inspection. The Registered Provider stated that a lot of work had already been completed in the past few months including a new boiler and pressure tank so that the hot water and heating is assured in the home, a new shower room installed so that residents have a choice of shower or bath, hallways and passageways regarding-papered and painted, and the home is to be recarpetted. The Registered Provider said that the facilities inherited were not of a good standard and he is improving it. It is recommended that the home should be signed to assist residents with dementia, e.g. calendar and clock to be displayed, relevant pictorial signs identifying different rooms etc. There were comments that the standard of cleanliness are not always good and that they were better in the past when there was a cleaner employed. The care staff team are responsible for domestic duties. As the majority of the shifts there are only two staff on to cover care and cleaning tasks this has presented a problem, which was reinforced when the inspector viewed facilities and found that whilst a number of area were clean and odour free there were some bedrooms that had odours and a stained carpet in a residents bedroom. A survey received from a resident said that the home was ‘usually’ fresh and clean. The toilets inspected did not have towels, soap or toilet paper. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 21 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): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels do not entirely meet residents needs. Recruitment processes are generally thorough to ensure the protection of residents from unsuitable staff. A staff training system is in place to ensure staff are aware of residents needs though this needs to be extended. EVIDENCE: There were comments made to the inspector that there was not enough staff to meet residents needs. The staff survey stated that there is a need for more staff to give more time with residents. There was also comments contained in a relative’s survey that staffing levels are inadequate to meet residents needs at night when there is only one Care Assistant on duty, leaving residents in wet or soiled pads all night. The Provider has stated that this does not happen in practice as staff had been instructed to change pads as needed. The staffing rota showed that for the majority of shifts times there were only two management/care staff on duty in the day time/evening to cover the fifteen residents currently accommodated (there is three care/management Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 22 staff on in the early part of the week for morning/early afternoon shifts though it did not appear to make consistent sense as to why this was not the case for seven days a week as care needs are broadly the same on each day of the week). With up to sixteen residents accommodated with the majority having dementia and care dependency needs (at the time of inspection there were eleven residents with a continence difficulty) then there appears to be a need to employ three staff on all daytime/evening shifts. There is currently no domestic staff member on duty. As discussed with the Registered Provider and Acting Manager, effective domestic cover is needed to ensure that all necessary work is done. The Registered Provider has stated that the home is to employ a cleaner for sixteen hours per week. There is one awake staff on duty at night to cover residents needs, with staff on call within twenty minutes of the home if needed according to the Acting Manager. There were previously two awake staff members on duty. The Registered Provider stated that he had carried out an assessment of the current duties of night staff and said that only one staff was needed. If this workload increases then another waking staff is needed to be employed on this shift. Staff recruitment files generally confirmed that proper recruitment procedures and checks have been followed though there was an oversight in regards to one file regarding a necessary reference, which was brought to the attention of the Acting Manager who said this would be followed up. There was evidence of induction programmes for staff on staff files though no evidence seen that new staff to undertake the Skills for Care induction programme. This needs to be put into place. The Registered Provider and Acting Manager said that staff were expected to undertake National Vocational Qualification level 2, and that there would be a minimum ratio of 50 care staff having this training, as per the National Minimum Standard when currently enrolled staff complete their courses. As regards other essential training, staff files contained evidence of training – e.g. food hygiene, fire, first aid, moving and handling, medication, Protection of Vulnerable Adults, and dementia etc. It also needs to include other issues – e.g. health and safety, Infection Control, challenging behaviour, Mental Capacity Act and any residents health conditions, e.g. – stroke, diabetes, Parkinson disease, hearing and sight impairment etc, which is necessary for staff to have a better understanding of these conditions and so be better able to assist residents. The Registered Provider has stated that staff training will be reviewed and required courses booked. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 23 On the day of the inspection, the Acting Manager was recommended to draw up a training matrix to indicate which staff needed training in what topic so this can be easily checked and planned. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 24 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): 31,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in not fully in place to protect the health and safety of residents. EVIDENCE: The Registered Provider needs to ensure that there is a Registered Manager in place in the short term to ensure the continuity of care for residents. The Registered Provider stated that there would be a Registered Manager in place shortly. There was evidence that staff are given formal supervision. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 25 The Acting Manager said that she did not keep any residents monies. This is instead carried out by invoicing residents representatives for any monies spent. There was evidence that the Quality Assurance system has been carried out for relatives views on the care provided. The Acting Manager said this would also be carried out for residents and other interested parties - District Nurses, GPs, Social Workers etc, an Action Plan will be drawn up to meet any issues that come up, and this information included in the Statement of Purpose. The Acting Manager said staff meetings are to be held frequently. It is recommended that the agenda be displayed before the meeting so that staff can record issues they want to raise. Fire Precautions: a fire drill is to be carried out on a three monthly basis. Staff were aware of the proper fire procedure. Fire bell testing was carried out on the required weekly basis. However emergency lighting testing was not being carried out on the required monthly. The Acting Manager said this would be followed up and put in place. There is a format for Risk Assessments for safe working practices to be carried out for issues that present risk for any issues that may present a danger to residents and staff, and this is to be done in the next few weeks following this inspection. This was needed as the inspector observed that there was a door open to the laundry room where Control of Substances Hazardous to Health were stored. An Immediate Requirements Notice was served for such products to be safely stored at all times. The Registered Provider said that the products would be secured until a working lock was fitted. There was also a bathroom undergoing refurbishment that was open, which was a tripping hazard and a fire door seen to be wedged in the main lounge, potentially compromising residents safety. There was also a discussion that there is an assessment regarding window restrictors to ensure they are sufficient to meet the needs of current and future residents. The Registered Provider stated that the health and safety file is now complete, monthly inspections being done and Risk Assessments in progress. The Registered Provider was asked to check with the Environmental Health Officer as to when the last visit to the premises was and if there were any outstanding Requirements. The Registered Provider said that he was currently ensuring that there was proper service contracts in place, e.g. for fire, hoist and wheelchair servicing, appliances etc. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 26 The Registered Provider said that radiator covers are to be fitted to prevent a burning risk to residents. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 1 STAFFING Standard No Score 27 1 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X X 1 Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement All care plans must be sufficiently detailed to enable staff to provide residents health, personal and social care needs; this includes keeping the care plan under regular review in consultation with the individual and revise the plan where necessary. Proper incontinence programmes must be in place. This will safeguard resident care and wellbeing. Staff always need to be respectful in their way of talking to residents. Regular activities and outings need to be offered to residents based on their preferences. The facilities of the home need to be upgraded to supply a well decorated, refurbished and homely environment. The premises must be kept clean and hygienic and free from malodours. DS0000070953.V355332.R01.S.doc Timescale for action 04/03/08 2. OP10 12 08/01/08 3. OP12 12 04/01/08 4. OP19 23 04/04/08 5. OP26 23 08/01/08 Silver Birches Version 5.2 Page 29 6. OP27 18 Staffing levels must be reviewed 08/02/08 and increased as necessary to be able to meet the needs of residents at all times. The staff training programme needs to be extended to cover all identified issues relating to the care of the residents. 04/07/08 7. OP30 18 8. OP31 9 The Registered Provider needs to 04/04/08 ensure that a competent Registered Manager is in post. Health and safety systems must 08/02/08 be fully in place and cover residents from the risk of harm, that Risk Assessments of all safe working practices are in place, to ensure all fire issues are fully covered, that equipment is properly stored and there must be secure arrangements for storing Control of Substances Hazardous to Health items. 9. OP38 23 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 OP15 Good Practice Recommendations Offering residents a set choice of main meal is recommended and ensuring that food is served at suitable temperatures. Silver Birches DS0000070953.V355332.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 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. 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