Inspection on 27/04/05 for Silver Birches - North Yorkshire County Council

This inspection was carried out on 27th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Silver Birches - North Yorkshire... 13/01/07

Silver Birches - North Yorkshire... 14/12/05

Silver Birches - North Yorkshire... 15/12/04

Silver Birches - North Yorkshire... 21/07/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Silver Birches Station Avenue Filey North Yorkshire YO14 9AH Lead Inspector Pauline ORourke Unannounced 27th April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Silver Birches Address Station Avenue, Filey, North Yorkshire YO14 9AH 01723 513563 01723 513006 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) North Yorkshire County Council Paul Farmer Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15.12.2004 Brief Description of the Service: Silver Birches is a purpose built property standing in its own well maintained grounds. It is situated a few minutes walk from the town centre. The building, occupying two floors, provides accommodation for a maximum of 31 residents. There are 22 places offered on a permanent basis and five available for respite care. A four-bedded rehabilitation unit is also provided jointly with the health authority. A ten-place day centre is also available. The rooms offered are all single. There are communal bathrooms and toilets on each floor. There is a passenger lift. Communal rooms are located throughout the premises. Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 15 hours A tour of some areas of the building was conducted. A number of the residents records, staff records and records about the management of the home were inspected. Seven of the 21 residents, five of the nine staff on duty and one physiotherapist were spoken with. What the service does well: 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Residents are admitted without a full assessment. Which means there is no assurance their care needs will be met. EVIDENCE: North Yorkshire Social Services admissions policy allows for the registered manager to carry out their own assessments prior to a resident being admitted. Recent admissions made to the home relied solely on the assessments provided by care managers. and the registered manager could not assured of meeting the resident’s needs within the context of current provision within the home. Individual records are kept for each of the residents and inspection of four of these records did not contain full assessment information for them. Two of the files seen were of residents recently admitted to the home. The residents spoken to confirmed that they had not seen anyone from Silver Birches prior to their admission. The duty manager also said that they had not assessed those residents recently admitted and were not able to reassure the residents their needs could be met at Silver Birches. Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 10 The residents personal and social care needs are met despite them not being involved in the care planning process. EVIDENCE: The individual records kept for the residents contained a ‘Promotion of Independence Plan’. These plans contained a break down of the assistance required by the resident and covered all aspects of health, personal and social care. This information was supplemented with a personal history identifying major events in a residents’ life that may have an impact on their care. The Promotion of Independence Plans are reviewed on a monthly basis. A contact sheet is also maintained. Entries are not always made on a daily basis but they are made on a regular basis. None of the residents spoken with knew that they had a care plan. A key worker system is operated in the home, yet the residents spoken with were not clear as to whom their individual key worker was. The staff spoken with clearly understood their role as ‘key worker’ All the residents spoken with felt that staff treated them with respect. One resident felt that they did not always observe her right to privacy when Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 9 entering her room. During the inspection the interactions between staff and residents were seen to be relaxed, respectful and friendly. Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 13 Social activities were well-organised and provided stimulation and interest for the residents. EVIDENCE: Organised activities are advertised in the dinning room and there is something planned every day. This plan is supplemented when entertainment is brought in to the home. Several residents said that they enjoy the activities and ‘try to join in with everything’. One resident looked forward to the residents meetings. The residents said that the staff who organise the activities don’t force people to take part. The routines of the day are flexible although several residents spoken with were not aware that they could take their meals in their rooms if they wished. Residents are able to access their rooms at all times through the day and several take the opportunity to have an afternoon nap. Residents and staff confirmed that there are no set routines for the day and one resident spoken with confirmed that she has a late start to the day having breakfast in her room. She also said that when she initially came to the home she took all her meals in her room but decided she would benefit from taking some of her meals in the dining room. There is a visitors’ policy in place and whilst the opportunity to speak to visitors was not available during this inspection the residents said that their visitors were always made welcome and offered refreshments when they Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 11 arrived. The staff spoken with were aware of the family involvement of many of the residents and where they were key workers worked with the families. The visitors book showed regular visits are made by families of the residents. Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents were confident that any complaints or concerns they had could be raised and acted upon. Residents are not fully protected from possible abuse. EVIDENCE: North Yorkshire Social Services has a detailed complaints policy. This policy is provided to all the residents and is displayed around the home. There have been no complaints made to the CSCI or the home in the last 12 months. Residents spoken with all said that if they had any problems there was someone within the home they would go to. North Yorkshire Social Services also has an Adult Protection Policy and procedure in place. Staff spoken with were clear that they would report any suspicion of adult abuse to the duty manager. They confirmed that they had not received any recent training in this procedure. Staff have also been deployed without a disclosure from the criminal records bureau so the management cannot guarantee the safety of the residents. Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The home was clean and well maintained with the exception of the dinning room carpet. EVIDENCE: During the inspection several areas of the home were seen and found to be clean and odour free. The communal areas were comfortable and warm. The furniture was said to be comfortable by the residents. The home is located close to shops and is suitable for its stated purpose. A maintenance man is employed and the domestic staff keep a log of any small repairs required around the building. The grounds are well maintained and accessible to the residents. The residents have access to a courtyard where seats and parasols are provided. The dining room carpet was identified at the last inspection as requiring cleaning or replacing, this issue remains outstanding. Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 The residents have not been protected from possible abuse as the procedures for the recruitment of staff have not been followed correctly. EVIDENCE: There has been a low turn over of staff in the last twelve months. The staff files of two staff members employed in that time were inspected and were found to contain all the necessary documentation as required by the Care Homes Regulations 2001. The criminal records bureau disclosures, however, were dated after the commencement date of the employee. The duty manager did confirm that the member of staff had a POVAFIRST check but there was no evidence to support this so the protection of the residents could not be guaranteed. The residents spoken to said that the staff were ‘first class’ and ‘very nice’. They said that the staff were helpful and they appreciated the fact that they organise some of the activities whilst being very busy. Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The health and safety of the residents and the staff is promoted. EVIDENCE: The staff spoken with during the inspection said that they had received training in, back care, first aid, food hygiene, COSHH, and fire training. Evidence of this was seen in their records and in the office diary. The equipment used in the home is serviced at the prescribed intervals with the exception of the portable hoists and bath hoists. Health and safety notices were displayed around the building. Accidents are properly recorded and were appropriate reported to the CSCI. Information from the accident records is used in the care planning process. All staff have access to Induction and Foundation training. Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 16 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 1 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 x x x x x x x 1 Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 17 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 18 19 Regulation 13(6) 23(2)(d) Requirement All staff must have training in the Adult Protection Procedure The dining room carpet requires cleaning or replacing. (Previous timescale of 30th January 2005 not met) Staff must not be deployed until they have received a criminal records bureau disclosure or a POVAFIRST check has been provided. The registered manager must provide the CSCI with evidence that the lifting machinary has been serviced. The registerd manager must also ensure that the fire alarms are tested on a weekly basis in accoradance with advice given by North Yorkshire Fire and Rescue Service. Timescale for action 29.05.05 29.05.05 3. 29 19(1)(b)i 27.04.05 4. 38 23(2)c, (4)c v 29.05.04 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 3 Good Practice Recommendations A member of the management team should carry out their J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 18 Silver Birches 2. 7 own assessment of potential residents and keep a record of this assessment. Residents should be kept fully invovled and informed of their care plan. Silver Birches J53_J04_S34517_Silver Birches_V221760_270405_Stage 4.doc Version 1.20 Page 19 Commission for Social Care Inspection Unit 4 Triune Court Monks Cross York YO32 9GZ 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. 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