Inspection on 10/02/06 for Silverbirches

This inspection was carried out on 10th February 2006.

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

Silverbirches 29/11/06

Silverbirches 15/05/06

Silverbirches 06/09/05

Silverbirches 29/03/05

Silverbirches 22/07/04

Silverbirches 08/12/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Silverbirches 23 Tyne Close Chelmsley Wood Birmingham West Midlands B37 6QZ Lead Inspector Sean Devine Unannounced Inspection 10th February 2006 10:30 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 Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 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. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Silverbirches Address 23 Tyne Close Chelmsley Wood Birmingham West Midlands B37 6QZ 0121 788 3758 0121 788 3956 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) Accord Housing Association Limited Mrs Stephanie Matthews Care Home 50 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (35) of places Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Can admit one named Service User (CH) aged 61 years. Can admit one named Service User (CS) aged 62 years. Date of last inspection 6th September 2005 Brief Description of the Service: Silver Birches is a purpose built two storey residential home for older people set in the Chelmsley Wood area of Solihull. The home opened in 2001 and is divided into three units. One unit (Kingfisher) is registered for 15 older people with dementia. Two units (Robin & Jay) are registered for frail elderly residents with facilities for 17 and 18 residents respectively. All rooms are single with en suite facilities. Within easy reach of public transport. Amenities such as shops, library, park and sports centre are located a 10-minute bus ride away. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was conducted by two regulation inspectors on an unannounced basis, this following the commission receiving two complaints. The focus of this report is upon findings in respect of the complaints and subsequent action where needed to improve the service to residents. To fully investigate the complaints the inspectors viewed records in respect of care provision and spoke to both residents and staff. Requirements from the last inspection have not all been fully assessed and many have been carried forward. It is recommended that the previous inspection report dated the 6th September 2006 be considered when reading this report. Within this report there are detailed many positive outcomes for residents. The following areas of the summary have been completed based upon outcomes for residents following the complaint investigation. What the service does well: What has improved since the last inspection? What they could do better: The home must plan the care and manage the risks of residents effectively, ensuring that residents have access to relevant health services such as a GP when their physical health changes. Health records must be fully and accurately completed. Residents must have available their medication as prescribed by the GP. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 Page 6 The home must ensure that a record of food and fluid offered and consumed by residents who are identified as at relevant risk is maintained and ensure that alternative food supplements are considered where a need is identified. Staff in adequate numbers who are experienced, competent and effective in care delivery must always be available to support residents. Communication between the care staff, senior staff must be improved to ensure residents’ needs are effectively managed. 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. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 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 Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 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): Standards in respect of choice of home were not assessed. No judgement. EVIDENCE: The home does not provide an intermediate care service. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 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 Residents care needs are not always well planned for and are not always met, this includes managing risks and changing needs. Residents’ medication is not always available when needed increasing the risk to their health and wellbeing. EVIDENCE: Concerns were raised within a complaint questioning the standard of care for one resident. This complaint is upheld. With regard to changing health care needs; no care plans or risk assessments were available to inform staff of how to meet the changing needs of a resident. Health records to monitor fluid intake were not fully completed and where concerns had been raised by care staff in daily records, in respect of deteriorating health, the GP had not always been informed. Another complaint described that the home does not always protect residents from possible risk. This complaint is upheld. Records indicate that a risk to one residents safety is prevalent however no risk assessment or strategy to reduce risk had been developed and implemented. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 Page 10 Medication records for one resident indicate that pain relief was prescribed, however this medicine was not always available to administer to the resident when it may have been needed. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 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): 15 The home is failing to meet the dietary and nutritional needs of residents, changing needs are not quickly identified and appropriate actions are not taken. EVIDENCE: One complaint raised concerns regarding the fluid and dietary intake of a resident. This element of the complaint is upheld. It was evident that the staff had been monitoring the intake and recording it. However some records were not available and some indicate food was not offered for long periods whether declined by the resident or not. The records seen indicate minimal intake and other records indicate the resident being unwell, this was not fully reported to the GP, and no evidence of food supplements were recorded. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 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 the following standard(s): 18 Residents ‘needs in respect of being protected from abuse are met, the home acts quickly and are aware of what constitutes a risk to the health and welfare of residents. EVIDENCE: One element of a complaint raised concerns that a delay in referring under local authority adult protection procedures increased the risk to a resident. This element of the complaint is not upheld. Records and reports indicate that the manager acted promptly to raise their concerns with Social Care and Health and that during this period of time the staff were alert to any other risks to residents. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 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 the following standard(s): Standards in respect of the environment were not assessed. No judgement. EVIDENCE: No evidence. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 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 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 Residents’ needs are not always fully met by a complement and skilled group of staff great enough to meet their individual needs. EVIDENCE: An element of a complaint raised concern that there was not always enough staff on duty, this element of the complaint is upheld. On one unit there are four care staff on duty during the day until 9.45 pm, one of whom is a senior care assistant. At night there is one care staff on the unit from 9.45 pm onwards, supported by one senior care assistant who also assists the one member of staff on the other two units. The staff rotas for week including the 10th February 2006 indicate that the three night care workers were all from an agency. The protection plan following the adult protection referral includes one member of staff being within the close proximity of one named resident when not in the bedroom, it is evident that this is not possible after 9.45 pm. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 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 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): 31 At times poor communication between care staff, seniors staff and managers has resulted in residents needs not being adequately met and their health and safety has been negotiated. EVIDENCE: The inspectors viewed residents’ records including information recorded on a daily basis by the team of care staff. It was a concern that some entries made had not had appropriate follow up action, information in the senior staff communications book did not always include concerns raised by care staff in the daily records of residents. At times the clear lines of accountability and responsibility are not fully followed through. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 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. 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X X Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 Page 17 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 OP7 Regulation 15(1) Requirement The registered person must ensure that residents who have needs in respect of challenging behaviours have a written care plan and a risk assessment. Previous timescale 31/10/05 not met, this requirement is carried forward. The registered person must ensure that all care plans are reviewed on a monthly basis, this must include how effective or otherwise the plan has been. Not assessed and is carried forward. The changing needs of residents must be fully and promptly assessed, including their changing physical health, the identified needs must have a care plan and where needed a risk assessment developed. The registered person must ensure that the personal risks of residents are fully assessed and where needed a risk assessment and management plan are Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 Page 18 Timescale for action 28/02/06 2. OP7 15(2(b) 28/02/06 3 OP8 14(2) 17/02/06 4 5 OP8 OP8 12(1) 15(1) 12(1) 6 OP8 12(1) implemented. All health care records must be fully maintained as identified in a care plan. The registered person must ensure that the GP and relevant healthcare services are promptly informed of the changing healthcare needs of residents. The registered person must ensure that residents who have potential or current risks in respect of nutrition and tissue viability have a risk assessment completed. Not assessed and is carried forward. The registered person must ensure that gaps on the medication administration records are investigated and corrective actions taken. That all creams and ointments are dated when opened and then disposed after 28 days. The registered person must regularly audit all medicines in respect of current stock control and any inaccuracies must be fully investigated and corrective actions undertaken. 17/02/06 17/02/06 28/02/06 7 OP9 13(2) 24/02/06 8 OP9 13(2) 9 OP15 12(1) 13(4) 16(2)(i) Not fully assessed and is carried forward. The registered person must 10/02/06 ensure residents have their medicine administered as prescribed by their GP. The registered person must 17/02/06 ensure that a record of food and fluid offered and consumed by residents who are identified as at relevant risk is maintained. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 Page 19 10 OP15 16(2(i) The registered person must ensure that alternative food supplements are considered where a need is identified. The registered person must ensure daily food menus are clearly advertised on all units and available for residents. The registered person must ensure condiments are provided at mealtimes and the orientation board is altered to reflect whether it is breakfast, lunch etc. 28/02/06 11 OP27 12 OP28 Not assessed and is carried forward. 18(1)(a-c) The registered person must ensure adequate staffing numbers who are competent are made available to implement the protection plan following the recent adult protection strategy meeting on Kingfisher Unit and who are experienced and knowledgeable with the homes policies and procedures. 18(1)(c,i) The registered person shall ensure that 50 of care staff employed have achieved a minimum of NVQ level 2 or equivalent. 10/02/06 31/03/06 13 OP30 18(1(c, i) Not assessed and is carried forward. The registered person must 31/03/06 ensure that all staff receive up to date training in all safe working practices based upon the TOPSS induction programme, this must urgently include Fire Safety training. Not assessed and is carried forward. The registered person must make an application to register a DS0000004520.V283076.R01.S.doc 14 OP31 CSA 2000 31/03/06 Page 20 Silverbirches Version 5.1 manager with the CSCI. Previous timescale of 30/11/05 not met, this requirement is carried forward. The registered person must ensure that the day to day operations of the home including reporting and acting upon important information in relation to residents is conveyed promptly to required professionals internal and external to the home. The registered person must ensure that staff are provided with frequent supervision in line with national minimum standards. Not assessed and is carried forward. The registered manager must ensure all staff attend a minimum of two fire drills and records must be maintained. The registered person must ensure that the recommendations made by the fire officer at his visit on the 28/7/05 are fully implemented. Not assessed and is carried forward. 15 OP31 18(1)(a) 12(1) 10(1) 17/02/06 16 OP36 18(2) 28/02/06 17 OP38 23(4)(e) 28/02/06 Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 Page 21 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 YA8 Good Practice Recommendations It is recommended that the registered person provide staff with supervisory responsibility with appropriate training. Silverbirches DS0000004520.V283076.R01.S.doc Version 5.1 Page 22 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. 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