Inspection on 15/05/06 for Silverbirches

This inspection was carried out on 15th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 10/02/06

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 15th May 2006 08:50 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.V290695.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.V290695.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.V290695.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Can admit one named Service User (CH) aged 61 years. Can admit one named Service User (CS) aged 62 years. That the home can admit up to three residents outside the registration category who are 60 years or over. 10th February 2006 Date of last inspection 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. The home is fully accessible on all floors from a passenger lift; there are wide corridors with handrails providing ease of access throughout. Each unit has its own dedicated communal lounge and there is a large additional lounge on the ground floor that is used regularly by residents and staff for activities and also to host meetings. On each unit there are facilities for bathing and taking a shower, these are large assisted facilities providing a safer environment for staff to support residents with their personal care needs. All meals are provided at the home, the kitchen is large and well equipped to adequately cater for the 50 residents, there is a dedicated dining area for the residents on Kingfisher and Robin and Jay unit share a large dining room on the ground floor. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was conducted by two regulation inspectors over a period of one day. The inspectors were able to meet many residents and some relatives. Staff were interviewed on an informal basis. Records for five residents regarding what care they receive and how they were receiving it were seen and a tour of the premises for two of the three units was undertaken. Other areas including the laundry and kitchen were also inspected. What the service does well: Residents are assessed prior to moving in to the home, this enables the home to make a decision on whether they can meet the needs of the resident. Many of the residents were unable to share their views and opinions of the service, however it was evident to the inspectors through non-verbal communication that there was a degree of contentment and happiness amongst most residents. Relatives informed the inspectors that they were generally happy with things at the home. The home does manage all medicine for residents; records of how it is managed and administered are good. There are staff available to support residents with planned activities such as craftwork, skittles and prize bingo. To help the staff plan activities key workers and residents complete an assessment called life history; which helps identify the likes and dislikes of residents. Residents are supported through good policies and staff practices to raise any concerns or complaints, records of these are available. Staff receive training in protecting vulnerable people from abuse, dementia awareness and challenging behaviour. The home continues to advocate for residents who they have concerns for and raise concerns with others such Social Workers and GP’s. The environment enables residents to be well supported, both individually and as a group. Many residents’ rooms and communal areas have high standards of fixtures and fittings, furnishings and décor and there are good facilities within the laundry and kitchen. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 6 Staff are recruited to ensure that residents are well protected, they ensure that all required checks such as criminal records bureau disclosures are made prior to offering employment. The premises are well maintained, a maintenance person is employed and all required service and tests of equipment and utilities are completed. What has improved since the last inspection? What they could do better: Care plans need to be clear and concise, they must inform staff what they must do in order to meet the needs of residents. Risk assessments have not been developed for nutrition and tissue viability, this was a previous requirement and it is also a serious concern that moving and handling and falls risk assessments are not adequately completed. Risk assessments for healthcare needs must be further developed and include a good management plan. These areas require development to ensure the residents health and well-being is both promoted and protected. Information gathered in the life histories of residents must be used in developing care plans and risk assessments. For example the life interests and hobbies of individual residents should be included within an activity care plan / programme. Residents who have immediate health concerns must have these reported to the GP; it is a concern that they may need to wait up to one week before seeing their GP. Medication must be stored in an area that is not hot and that may alter the effectiveness of the medicine. Staff who have not received training in safe working practices such as Fire Safety must do so. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 7 There is a need to provide a stable management structure and an application to register a manager with the commission is required. The acting manager has recently returned to her substantive position as assistant manager and a temporary project manager has been in post, the permanency of this position is to be reviewed in July 2006. An annual report on quality assurance following consultation with residents must be available in the home for residents, their representatives and the commission. Remedial works following a recent fire officers visit, an electrical installation test and passenger lift service are needed. 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.V290695.R01.S.doc Version 5.1 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 Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 The quality in this outcome adequate is poor. This judgement has been made using available evidence including a visit to the home. The residents’ needs in respect of choice of home are generally met; some improvements are needed to ensure staff can adequately meet all the needs of resident and to further develop trial visits. The home arrangements for ensuring choice of home is variable and improvements are required to ensure residents are appropriately placed and their needs can be met. EVIDENCE: Five residents were case tracked across three units. A detailed statement of purpose and residents guide is available, these documents describe the homes values, aims, resources and philosophy of care the residents guide also details accommodation, criteria and admission procedure, fees and views of residents at the home. These documents are available to all residents, relatives and interested persons. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 10 All files contained some pre-admission information; the amount of information was different on each file. This information had been made available mainly by social workers in the form of care plans and reports. The staff at the home had completed other assessments; these identified some needs regarding daily living, choices and risks. One member of staff advised that residents are offered a visit, usually to come to the home for a meal, however very few residents do come for this meal. Of the five residents four had two contracts, one issued by Solihull Council and one by the Accord Organisation, it was evident that relevant information is recorded in these contracts such as fees to be paid, room to be occupied and terms and condition of residency. Some contracts had not been signed by resident or relative or by the manager of the home. Some staff have received training to meet the specific needs of residents such as Dementia Awareness, Care of Medicines and Challenging Behaviours and during the visit staff were observed to be considerate and respectful when assisting residents. However some staff have not received induction training based upon Skills for Care or TOPSS standards. Staff in conversation with the inspectors appeared knowledgeable about the needs of residents and also described their concerns where they felt they could not meet the needs of one particular resident. The home does not offer or provide a service for intermediate care. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. The homes capacity to meet residents’ needs and identify risks is poor and could lead to residents being placed at risk to their health and welfare. EVIDENCE: All five residents had care plans available; most of the plans were signed by residents. Some had been written in first person others in a different tense; it was evident that attempts to develop person centred planning had started. Examples of care plans include “I like staff to spend time with me”, “I am a very active lady and enjoy helping with cleaning” and “ I like to choose my food on a daily basis, I don’t like fancy or spicy food”. To support the care plans other assessments were available or in the process of being completed including a Life History which identified significant events, formative years, occupational history, hobbies and interests, likes and dislikes and important photos. This document helps staff get to know the resident, and it is important that relevant information is used for developing the care plans such as relationships, activities and emotional well being. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 12 Several care plans declared that staff will assist, however the care plans did not instruct staff of what they must do to assist the resident; for example one care plan stated staff will intervene, how is not recorded and another care plan written for malnutrition and dehydration required a food and fluid chart to be maintained; it was not evident when this would become a serious health concern and which health professionals needed to be involved. Other care plans were well written, for example a mobility care plan advised to use a zimmer frame but for longer distances a wheel chair needs to be used. Care plan reviews were seen to be completed on a monthly basis, little information of how effective the care plans had been was recorded, changes had been identified, some records of healthcare visits had been recorded and many had been signed by residents. Of the risk assessments sampled some had been developed for personal risks such as medication, epilepsy and diabetes. The diabetes risk assessment included a clear management plan to reduce risks, however the epilepsy risk assessment only included complying with medication and not what can be done to prevent seizures or what staff must do in the event of a seizure. One risk assessment for mobility did not include details of visual impairment and another risk assessment for a chest infection did not inform staff of what they must do if the infection is diagnosed. Throughout all files one or more of the following risk assessments were not available, nutrition, falls, tissue viability and moving and handling. Residents do have access to community healthcare services such as their GP (who visits the home weekly), district nurses, chiropodists and dentist. Records are difficult to audit as information is recorded on different forms, such as daily records, doctors file and monthly care plan reviews, this was discussed with the project manager and inspectors advised that one record of healthcare appointments and visits would enable quick and effective access to information. It was a concern that one resident had recorded in daily records that she was not so well and had a sore throat and also had problems sleeping, the entry included “added to doctors list”, it was apparent that it would be approximately one week before the doctor was due to visit the home. The project manager advised that the GP service had requested that minor ailments should not be reported for a doctors visit but added to the doctors weekly visit list. One resident has recently been reviewed and discharged by the CPN, however the staff have concerns about meeting the needs of this resident. It is imperative that the home raises their concerns with the social worker and GP and fully documents these concerns within a risk management framework. A letter of serious concern was sent to the Responsible Individual detailing concerns in respect of the lack of risk assessments and risk management plans. On two of the three units the management of medicines was assessed, the home manages and administers all medicines for the residents. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 13 The concerns raised by the pharmacy inspector at her visit in March 2006 were followed, it was evident that recording on the medication administration records had improved, including the coding of medicine not administered, that the clinic room temperatures should be monitored, it was evident that the one room often exceeded 25°C and that medication fridges must have maximum and minimum temperatures recorded, no such thermometers were available. It was evident that many creams and ointments opened by staff had not been dated. The other requirements were not assessed at this inspection and are carried forward. Staff were observed supporting residents, all personal care was given ensuring the privacy of residents was maintained. Staff were observed being friendly to residents and their visitors and all staff new the names of residents and how to address them. At all times when residents used the toilets with staff support the doors were locked. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The daily life and social activity needs of residents are met, care planning and the development of life histories must be reflective of support given to residents and records kept must evidence this. EVIDENCE: As recorded in health and personal care the case tracked residents files included a life history, many social and community contacts were recorded and so were the preferences of residents in respect of hobbies, interests, activities and meals. All files had an activity tracker form, the form for some residents often recorded activities such as spending time in their room, or in the lounge recording their whereabouts and not what activity they were undertaking. The activity form had coded entries, many of these were not used and although many of the residents had their choices recorded in life history care plans they were not fully reflective of this, for example, relationships care plans did not record how families are involved in the lives of residents and how key workers encourage and support residents to keep contact. The care plans for interaction and activity referred mainly to planned activity and did not record how staff support residents through daily interactions. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 15 During the inspection residents were invited to take part in the planned activity session, these are planned on a daily basis for the week by the activity coordinator, the co-ordinator was not on duty and her role was covered by a care assistant to ensure activities are always available. The activity planner included painting, card making, skittles, film afternoons, prize bingo and many other pastimes. The large “blue” room is often used for these planned activity sessions. All residents files had a care plan, titled Food and Drink, these plans were more informative and described many likes, dislikes and portion sizes and also alerted staff to any special diets; where risks were involved a risk assessment was available with a management plan. There were food and fluid charts available on the files of two residents, it was not clear through care planning when they were initiated, how they were to be managed and only some had been signed by a senior when completed; the daily records often referred the reader to the charts. One inspector sampled and observed a lunchtime meal, staff were seen appropriately encouraging residents to eat their meals and the food was palatable. Residents were offered an alternative if they did not want to eat, for example yoghurts, soup and ice cream. One resident was given a food supplement and encouraged to drink it. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Residents are able to make complaints and raise concerns; these are listened to and responded to. Staff are able to identify areas of concern and are trained to protect residents from possible abuse. The staff raise their concerns with appropriate agencies yet they must ensure recordings are accurate and that the information shared with other agencies is at all times factual. EVIDENCE: The inspector was provided with the up to date version of the complaints policy, this was available in the foyer area of the home. The policy defines a concern and a complaint and guides the resident or their representative through how to make a complaint, the rights of the person making the complaint and how complaints are managed and investigated. There is a form available for the person wishing to make a complaint. The complaint log was available at the home, two entries had been made since the last inspection, the details were well recorded and the dates of when they were responded to were entered, if the complainant was happy with response is also recorded, however what the response was is not. The log did not record the outcome of the complaint. The commission investigated two complaints at the last inspection; no other complaints have been received since this time. Relatives indicated that they had no concerns. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 17 The inspector was informed that the adult protection policy had not altered. The staff training matrix indicated that in excess of 50 of staff have completed training in Adult Protection and the project manager advised that this is planned within a rolling programme. Staff freely discussed their concerns they have about meeting the needs of one resident with an inspector and the management have raised their concerns with the CPN, who was not concerned. There has been a case review. Since the inspection the project manager has confirmed that minutes of the review have been received, she agrees after discussing them with the inspector that they are not fully reflective of the home being unable to meet the personal care needs of this resident, and although the home is being flexible in creating strategies to meet these needs they are not adequately meeting them. The inspector advised that the project manager discuss these minutes, concerns and outcomes with the social worker. Since the inspection visit there has been an adult protection meeting regarding the health and welfare of some residents involving Social Care and Health and Contracts from Solihull Council. Concerns had been raised by the home of a serious nature, as an interim measure referrals to the home have been suspended whilst these concerns are investigated. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 18 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): 19, 20, 21, 22, 23, 24, 25, 26 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The environment enables residents to be well supported individually and as a group, providing very good standards of fixtures, furnishings and décor and good facilities within the laundry and kitchen. EVIDENCE: A conducted tour of Kingfisher and Robin unit was taken. Kingfisher and Robin unit were found to be well maintained, it was evident that routine maintenance was in place. Kingfisher has a lounge / dining area and a quiet lounge, whilst Robin unit has a lounge with a kitchenette area and a large dining area that is shared with residents from Jay unit. All units have access to a large lounge on the ground floor known as the “blue” room. The gardens are accessible from Robin unit. All the communal areas were found to be pleasantly laid out and well furnished. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 19 All residents’ rooms have an en-suite toilet and wash hand basin, these were found to be clean and personal items such as toiletries were available. Kingfisher unit has a large assisted bathroom with hoist chair into the bath; the shower room is a walk in facility but also allows comfortable access for a shower chair. Robin unit has two large fully assisted bathrooms and a large assisted shower room, all are accessible close to residents’ rooms. Each unit also has two communal toilets, which are large and allow room for staff to assist if needed. All toilets and bathrooms have well placed grab rails, the corridors have handrails, the first floor is accessed by a passenger lift and a hoist “trixie” style is available on each unit. The inspector was advised that there are no residents on Robin unit who need to use the hoist. Residents have adequate space to safely use their zimmer frames and wheelchairs were also safely able to access all areas. Residents’ rooms on Kingfisher and Robin were sampled, they are all identical in size and fixtures and fittings, the décor in many rooms was individual however one room had no wall decoration and was very bland, this room also had a very strong odour and for a male resident it was painted pink. Lighting and heating is good in all communal and residents rooms, including central heating and large windows for natural lighting. The laundry has access for dirty laundry and egress for clean laundry. The floor is impermeable and the area is clean, sluice cycles are available on the two large commercial washing machines. Good hand washing facilities are available in all high-risk areas such as kitchens, toilets, sluice rooms and bathrooms. The kitchen was clean including all equipment and records of cleaning, temperatures of fridges and freezers and food probing are well maintained. It is recommended that samples of food prepared and cooked be maintained for at least five days. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The staff are safely recruited to protect residents, they do receive training to national standards and also service specific training. At night there are not enough staff to meet their immediate needs and some staff have not received safe working practice training, which may put residents at risk. EVIDENCE: Staff rotas are available. During the day hours there are three care assistants on Kingfisher unit and two on Robin and Jay units, also one care assistant floats between Robin and Jay. These care assistants are supported by additional senior care staff, one covering Kingfisher and Jay unit and also one to cover Robin Unit. At night there is one care assistant on each unit all supported by one senior care assistant, the project manager was advised that these levels at night need to be reviewed to ensure that all the needs of residents can be timely and safely met. There are two assistant managers who do not routinely work on the units but who do provide support when needed. There are additional ancillary staff for cleaning, laundry, kitchen and maintenance. The pre-inspection questionnaire completed by the project manager and the assistant managers indicates that 58 of staff have an NVQ 2 in Care or above, of the two sampled staff training files one had evidence of this award. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 21 Staff recruitment files included a CRB and two written references, a detailed application form and evidence of interview records. Staff have job specification and job descriptions available on their files and receive these documents as part of the recruitment process. There is a detailed staff training matrix available, for some staff it was evident from this records that training in safe working practices such as fire safety, infection control and food hygiene. The inspectors were informed that staff are trained on a rolling programme, it was thus clear that staff do not always attend as other staff had received much of the safe working practice training, it was a serious concern that several staff had not received fire safety training since 2003 and 2004. A letter of serious concern was sent to the registered individual regarding training staff in fire safety. The training files for the two staff also included additional training (service specific) such as care of medicines, adult protection, dementia awareness and challenging behaviours. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 22 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, 33, 35, 36, 38 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The management on a day-to-day basis requires a period of stability. The performance of the home is not audited and no quality reports are available to residents and their representatives. Staff are not adequately supported through the supervision process. EVIDENCE: The previous acting manager has returned to her substantive post as assistant manager and a project manager is managing the home. The project manager advised that she has several years experience managing care services and two and a half years as a homes manager in elderly care and care of people with a learning disability. She advised that she has completed an NVQ 4 in care and the RMA. She also confirmed that managing the home was a temporary position, which is to be reviewed towards the end of July 2006. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 23 Unannounced visits by a senior manager are regularly conducted and reports are made available at the home and also sent to the commission. Minutes of regular residents and staff meetings are available; these minutes discuss such topics as activities, care plans, issues of residents, the role key workers and menu reviews. There is a folder in the home known as Residents Participation; this folder contains information gathered through questionnaires and an invite to residents and their relatives regarding a consultation on catering in the home. Other items included advertisements for activities and following the gathering of information an action plan and a collation was completed. It is not evident that a full quality system is in place through consultation with residents and no annual report is available. The home does manage money in safekeeping for residents, the vast majority is money paid into an individual account by the relatives of residents. Three residents have their personal allowances paid direct to the home by social services. Five accounts were sampled and in all cases records were available to reflect transactions, which all had respective receipts. Balances were found to be correct. Staff do receive supervision, two files were sampled and the frequency was found to differ due to the experience, staff sickness and whether there were concerns that needed to be discussed. The agendas were based upon roles and responsibilities. The frequency of supervision for one staff member does not reflect adequate support. The inspector has previously seen detailed risk assessments for fire, premises, food and staff; the inspector was advised that these continue to be regularly reviewed. Equipment used at the home such as residents hoists were found to be regularly serviced. There is a handyman employed for general maintenance and for more detailed maintenance the Accord Housing has their own technical department for other works. It was evident that all utilities such as gas, electric and water are frequently serviced and that the fire system is tested, serviced and maintained. Since the last fire officers inspection the home needs to liaise with the fire department to see what is needed in respect of a fire action plan. There were six items on the recent electrical report identified as needing work, there was no evidence that this has been done. The lift service report for the 4th November 2005 identified three areas to be remedied, it was not evident this had been completed. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 24 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 3 2 3 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 25 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 OP2 Regulation 5(1)(b)(c) (3) Requirement The registered person must that all residents have a contract and that Residents or nearest relatives have signed the contract detailing terms and conditions of residency. The registered person must ensure that all staff are skilled and experienced to meet the needs of residents. The registered person must ensure that residents have appropriate opportunity to visit the home prior to admission being agreed. The registered person must ensure that care plans contain specific instruction to staff, detailing how to meet the residents assessed needs. The registered person must ensure that all care plans which are reviewed on a monthly basis include how effective or otherwise the plan has been. Previous timescale of 28/02/06 not met, this requirement is carried forward. Timescale for action 31/07/06 2 OP4 12(1) 18(1)(a) 14(1)(a,c) 30/06/06 3 OP5 30/06/06 4 OP7 15(1) 30/06/06 5 OP7 15(2(b) 30/06/06 Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 26 6 OP8 12(1) 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. Previous timescale of 28/02/06 not met, this requirement is carried forward. The registered person must ensure that a risk assessment for falls is completed for each resident and a management plan implemented. The registered person must ensure that a risk assessment for moving and handling for each resident is completed and a management plan implemented. The registered person must ensure that the resident who has epilepsy has a detailed risk assessment and management plan. The registered person must ensure that the GP and relevant healthcare services are promptly informed of the changing healthcare needs of residents. Previous timescale of 17/02/06 not met, this requirement is carried forward. The registered person must ensure that that all creams and ointments are dated when opened and then disposed after 28 days. Previous timescale of 24/02/06 not met, this requirement is carried forward. All prescriptions must be seen prior to dispensing, checked and a system installed to check the dispensed medicines and the MAR chart received into the home. DS0000004520.V290695.R01.S.doc 30/06/06 7 OP8 12(1) 13(4) 30/06/06 8 OP8 12(1) 30/05/06 9 OP9 13(2) 30/06/06 10 OP9 13(2) 31/07/06 Silverbirches Version 5.1 Page 27 11 OP9 12 OP9 13 OP12 14 OP15 15 OP16 16 OP27 17 OP30 Not assessed and is carried forward. 13(2) Staff drug audits must be undertaken before and directly after a medicine round to confirm staff competence in medicine management. Not assessed and is carried forward. 13(2) The medication rooms’ temperatures must be monitored daily and fall below 25°C at all times to guarantee the stability of the medicines within. The installation of an air conditioning system may be needed to achieve this. Previous timescale of 20/05/06 not met this requirement is carried forward. 12(1) The registered person must 16(2)(m,n) ensure that care plans, for example relationships include information gathered from the life histories of residents and activity care plans include what residents interests are other than those identified in planned activities. 12(1) The registered person must 17(2) ensure that the food and fluid Sch 4(13) charts are signed as per the homes protocol by senior care staff and any concerns are recorded with action taken. 17(2) The registered person must Sch 4(11) ensure that the complaints log records the outcome of the complaint. 18(1)(a) The registered person must review the compliment of staff available at night to ensure that the needs of residents can be met in a safe and timely fashion. Additional staff must be provided where identified. 18(1)(c)(i) All staff must receive training in safe working practices; this must DS0000004520.V290695.R01.S.doc 31/07/06 31/07/06 31/07/06 30/06/06 31/07/06 30/06/07 31/07/06 Page 28 Silverbirches Version 5.1 18 OP31 CSA 2000 19 OP33 24 include fire safety training, food hygiene and infection control. The registered person must 31/07/06 make an application to register a manager with the CSCI. Previous timescale of 30/11/05 not met, this requirement is carried forward. The registered person must 30/08/06 ensure that regular consultation, which is recorded, is undertaken, to elicit its performance against the statement of purpose, aims and objectives. This must include residents, their representatives and stakeholders. An annual report on quality must be available in the home for residents, their representatives and the commission. The registered person must ensure that staff are provided with frequent supervision in line with national minimum standards. The previous timescale of 28/02/06 was not met, this requirement is carried forward. The registered person must ensure that after consultation with the fire service that a fire action plan is available and shared with staff and residents. The registered person must ensure that the items listed on the electrical installation report for remedy are fully completed. The registered person must ensure that the remedial work as identified in the latest lift service report is completed. 20 OP36 18(2) 31/07/06 21 OP38 23(4) 31/07/06 22 OP38 13(4)(a) 23(1)(a) 23(1)(a) 13(4)(a) 31/07/06 23 OP38 31/07/06 Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP15 OP8 Good Practice Recommendations It is recommended that samples of food prepared and cooked are maintained for at least five days. It is recommended that records in respect of healthcare received by residents be maintained on one form. Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Silverbirches DS0000004520.V290695.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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