Inspection on 29/11/06 for Silverbirches

This inspection was carried out on 29th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 15/05/06

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 Key Unannounced Inspection 08:50 29th November 2006 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.V314832.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. Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 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 Post vacant Care Home 50 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (35) of places Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 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. 15th May 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. The Commission was informed in the pre inspection information that the fees for this service are contracted at £381.00 each week. Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was conducted over two days by one regulation inspector. The home had provided a pre inspection questionnaire. The focus of the inspection was aimed predominantly on the residents who live on the Kingfisher unit, which is registered to provide a service for older people with dementia. The residents who live on this unit are not always able to effectively communicate their views and opinions about the standards of care they receive. Therefore some of the outcomes recorded in this report are made from other available evidence, including speaking to some relatives and staff and also from the inspectors’ view on the well being of the residents. The inspector also viewed records about the care of residents, including how care is assessed, planned and recorded, how residents personal lifestyles and choices have been considered and planned for and how any risks have been managed. The communal areas of the home were seen and how the health and safety of all residents and other people in the home is managed was assessed. The inspector assessed the home against all key standards and this included a national theme of standard 1, 2, 3 and 16 of the National Minimum Standards for Older Adults. During the inspection the inspector advised local social services of concerns including the protection of residents, management and administration including communication and reporting and staffing levels. Since the inspection a strategy meeting under protection procedures has been arranged. On day one of the inspection the home was issued two immediate requirements, firstly, regarding arranging a review of medicines including pain relief for one named resident and secondly, to develop risk assessments for this resident. On day two both immediate requirements had been completed. This is the second key inspection of the service this year and it is recommended by the Commission that the previous report dated 15/5/06 be considered when reading this report. What the service does well: Prospective residents and their representatives are provided with lots of information about the home and can consider this when making a decision on whether this home is suitable. Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 6 Residents are able to take part in the homes assessment of their needs, the residents have opportunity to raise their opinions, choices and preferences and this can be seen in how the care plans which describe to staff how to meet the residents needs have been written. Several residents and relatives indicated that they were satisfied with the standards of care at the home. Many relatives and friends were seen to visit residents over the two days of inspection, those who spoke with the inspector said that they can call at any reasonable time and that if they need to visits can be in private. Residents were seen to mainly enjoy their meals, which had been prepared in different ways depending on their needs, such as diabetic and a softer option. Relatives were complimentary of the meals at the home; one said “the food is usually very good, there’s always lots of choice”. What has improved since the last inspection? What they could do better: There are some very important areas where the home can do better and some of these areas that will have an impact and improve the health, safety and welfare of residents are as follows; Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 7 The home must ensure that very important information about the resident be available to them, including a full assessment of their needs before they accept residents on an emergency basis. It was a concern at the last inspection and at this inspection that the home does not always consult doctors where there has been a change in health condition or where it is apparent that the resident is in some discomfort. This must be improved as a matter of urgency. The home must ensure that after assessing all the needs of residents that they provide the correct number of staff to support the residents especially at busy times of the day for example, getting up, going to bed and at mealtimes. The home must ensure that significant incidents are reported to the local adult teams of the Social Services. The staff team must receive the necessary training to ensure they are skilled and competent to meet the needs of residents. 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.V314832.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 Silverbirches DS0000004520.V314832.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3 and 6. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the ability to ensure that residents are provided with the information they need to choose a home that can meet their needs and expectations. The process will be further improved for residents when the home completes its own assessments and can ensure the residents that their needs can be effectively met. EVIDENCE: Four residents were case tracked. The acting manager advised that a statement of purpose and a residents guide to the home are given to residents and their families when the home undertakes a pre admission visit and assessment, whether this is in hospital or at the home of the resident. These documents are also available throughout many areas of the home on notice boards. There were brief records of this pre admission visit by the staff with little evidence that an assessment was undertaken. Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 10 All four residents had some pre admission information such as care plans and risk assessments completed by social workers. However these documents did not always provide adequate information for the staff at the home to develop their own initial care plans, this was specifically a concern for one resident who was admitted as an emergency with very little information. This led to the first few days of the admission being distressing for the resident, as there were needs and risks that were not identified. All the residents had a contract, there were two for each resident, the first between the home and the resident and the second between the placing authority, the home and the resident. The information recorded included accommodation, fees to pay, services and referred to policies and procedures such as visitors and the complaint process. The residents were asked about the residents guide, statement of purpose, contract and also visits to the home and assessments before their admission, however all residents were unable to recall the events and documents. The home does not provide an intermediate care service. Silverbirches DS0000004520.V314832.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has demonstrated that it does have the ability at times to support residents with their individual health and personal care. However this is not always completed effectively to meet their immediate needs and responsive enough to prevent distress and relevant risks. EVIDENCE: Detailed assessments of need had been completed for three of the four residents. Identifying with their key worker what support they required. The assessment included lifestyles, choices and preferences and also recorded the strengths as well as the needs of residents. Where support is required a care plan had been written, these were clear and concise and guide staff in what they must do. They are written in a way that is person centred, as if the resident was saying what they require. These care plans were also available for health needs such as epilepsy. Risk assessments for three of the four residents were available, these assessed risks in the Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 12 following areas, manual handling, skin integrity, nutrition, falls and other personal risks relating to the individual resident. The management plans where a risk was identified were good, for example the manual handling risk assessment described equipment to be used. However for one resident a risk assessment was available asking for staff to monitor indicators of behaviour, it was not clear what these indicators were. The home manages all medicines for the residents. It is generally well managed, with good recordings and safe storage. Only staff who are trained can administer medication. Stocks of medicines dispensed in monitored dosage blister packs were found to be accurate however for medicine dispensed in bottles it was not. Guidance is available for staff when they need to administer “as required” medicine. A resident who was exhibiting signs of pain did not have any pain relief medicine. Health records were available for three of the four residents including access to primary care services such as GP, dentist and opticians and secondary health care through hospitals and outpatient appointments. The staff were observed being respectful to residents, at no time were there any concerns that the residents privacy was not being maintained, it was also evident that staff were keen to do their best for residents. For example some residents were seen to eat better when staff positively encouraged them. Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All standards The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has not demonstrated it has the ability to provide residents with the opportunity to take part in the daily life and social activity of their choice. This will increase their boredom and have an impact on the self-esteem of the residents. EVIDENCE: The home does have a full time activity assistant. Three of the four residents who were case tracked had an assessment, which included a description of their lifestyles; including relationships, families, culture, religion, work and occupation, leisure and pastimes. These often referred to what they particularly like and enjoy, such as food, dress and hobbies. Records of the daily and social activity of residents are recorded on a coded form, and it was not evident that the desired and individual activities identified in the assessment are available to residents. The form often recorded behaviours, rest and mental state. There was little evidence residents were Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 14 involved in purposeful activity and whether they enjoyed it or otherwise. Each unit had an activity planner on a notice board; this included many events such as prize bingo, arts and crafts, film afternoons and card making. Many relatives and friends were seen to visit residents over the two days of inspection, those who spoke with the inspector said that they can call at any reasonable time and that if they need to visits can be in private. There have been previous plans to commence a relatives group at the home. The senior managers who were available for feedback towards the end of the inspection advised that there are plans for these meeting to take place. Residents are provided with a cyclical menu. The meals appeared to be nutritional and varied and provided for special diets such as diabetic and a softer option. Staff were aware of the dietary needs of the residents and residents had been involved in planning the seasonal menu. On one unit the meals were served on plastic plates, when advised of this the acting manager immediately replaced them. During the lunch on one unit there was not enough staff on duty, the inspector was advised that there are normally three staff on this unit at meal times, however there were two staff and some support was offered by a senior care assistant who was engaged in administering medication. Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it ability to effectively manage complaints made to them, the process is quickly completed and where needed services to residents are improved. The home has not demonstrated that the residents are adequately protected, areas of concern are not quickly reported and some staff do not all have the skills to recognise abuse and maybe unaware of their responsibilities, this will leave residents at further risk. EVIDENCE: During the inspection social workers were investigating a complaint. The details of the complaint had not been shared with the home and they were unaware of the concerns, thus this complaint had not been recorded within the complaints records. As part of this investigation an adult protection strategy meeting was arranged. The home does maintain a record of complaints, this details all complaints received. The complainant is provided with a response about the findings and any subsequent actions. If the complainant has not responded it is deemed that they are satisfied with the outcomes and the complaint is closed. The pre inspection questionnaire indicated that in the past 12 months twelve complaints had been received at the home, all were substantiated and all were managed within the twenty-eight day timescale as required by the homes policy. During the inspection no residents or relatives had a complaint to Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 16 make, one relative advised that he was aware of who to make the complaint to and had information at home. The residents are provided with information in the statement of purpose, residents guide and within their contracts of how to raise a complaint and how it will be managed. The complaints policy was available on notice boards throughout the home. The pre inspection questionnaire recorded one adult protection referral in the past twelve months. During the inspection the inspector notified the Social Services of a concern and since the inspection a review meeting for one resident had been arranged and so has a general meeting under local adult protection procedures. It was a concern that the acting manager was not fully aware of an incident at the home. Staff training records were seen, it was evident that there are some staff that have not been trained in protecting vulnerable adults. Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 17 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 19, 20, 21, 22 and 26. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has not demonstrated that that the environment is well maintained and in some areas it is a hazard to the health and safety of the residents. This may put them at risk and also impact on their general well being. EVIDENCE: The communal areas on all units were seen, residents appeared happy with their surroundings and one relative commented it was okay. It was evident that much of the fittings, floors and décor require improving, for example kitchenette work surfaces are damaged and stained, some kitchenette cupboards are broken or damaged, the paintwork to shelving in bathrooms is stained and or chipped, the flooring in the lounge / dining areas has come away from the skirting and is heavily worn in places and some carpets in lounge areas are heavily stained. Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 18 Each of the three units has a range of bathing, shower and toilet facilities to meet the varying needs of residents, this includes assisted baths with hoists, large shower rooms with shower chairs and many grab rails and a range of toilets, some large some smaller with adaptations to support mobility and movement of residents. All facilities are close to residents’ rooms. Some of the bathrooms and shower rooms have been decorated to provide a less clinical and more homely environment. There were some concerns about odour management; this was also reported by relatives who raised a complaint about the odour on the Kingfisher unit as recorded in Standard 16. On the first day of inspection some toilets were noted to have odours, which later subsided, however the shower room on Robin unit had a strong smell from the drain and during the lunchtime on Kingfisher unit there was a strong malodour. It was also evident that areas of the home were not clean for example kitchenette work surfaces were dirty in joints, flooring was dirty where it had lifted away from skirting and between appliances on the floor was dirty. The laundry area has a dirty side in and a clean side out, and has commercial equipment to launder clothes, towels and bedding, behind the equipment was extremely dusty. All high-risk areas have good hand washing facilities. Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 19 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): All Standards. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has not fully demonstrated that staff are well trained and available in good numbers, this may mean that residents needs are not effectively met and they may be put at risk. However the staff at the home are safely recruited, which is a good measure to help protect residents from possible abuse. EVIDENCE: Prior to the inspection the Commission were informed that the numbers of staff at night had been reduced to three, with staff unable to take proper breaks and spending periods on other units assisting where two staff are needed often leaving a unit without staff for a period of time. The change from four to three staff was confirmed by the acting manager, who also advised that that due to the concerns this would be addressed and would revert back to four staff. The staff rota at the time of inspection indicated that four staff were on duty at night. The staff rota and the pre inspection questionnaire indicated that the home is using an increased amount of agency care staff, however the full name of these agency staff was often not recorded. At busy times of the day on one unit there is routinely three care staff on duty, however only two care staff were on duty during lunchtime and the senior care assistant needed to provide some help, this had a negative impact on time the staff could spend with each Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 20 resident and also distracted the senior care staff who was administering medicines to residents Senior care staff are included on the managers / senior staff rota, there are normally two senior care staff on duty, they are allocated units for which they are responsible for, and oversee the support to residents, supervise staff and administer medication. The pre inspection questionnaire completed by the acting manager stated that there are 33 care staff of which 18 had completed the NVQ level 2 award or above (being 69 ). Three staff recruitment files were sampled, it was evident that the home ensures that all required checks are completed before they offer employment and commence work. Evidence included Criminal Record Bureau disclosures, two written references, application forms and a health screening. A staff training matrix is available, it was evident from this that a training programme is available to many staff. Some staff are receiving training in safe working practices including, moving and handling, health and safety and food hygiene. However there are some staff that are not receiving annual refresher training in fire safety and some staff have not undertaken infection control training. Training to meet the specific needs of residents is also recorded this includes some staff undertaking adult protection, medication management, dementia awareness, epilepsy awareness and managing challenging behaviours training. One relative commented that the staff are caring and attentive to the residents. One resident indicated that some staff were nice. Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 21 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): Standards 31, 33, 35, 36, 37 and 38. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home does not fully demonstrate that the management and administration is effective to fully support residents. There are areas of concern including communication, record keeping and reporting that are not satisfactorily undertaken and that put the health, safety and well being of residents at high risk. EVIDENCE: The home has been without a permanent manager in excess of twelve months and during this time has had three managers in place in an acting capacity. An assistant manager currently supports the acting manager. The management rota indicated that on most days one of them is on duty. There have been concerns about communication; examples of these are being unaware of the nature of incidents and accidents in the home, not acting quickly to arrange Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 22 pain relief for a resident, not reporting under adult protection policy and not fully recording accidents. The acting manager has advised that she does not wish to manage the home but felt that due to the home having no manager it would help in the short term, but she did not know when a new manager would be recruited. There is an annual scheme review, which is completed following a cycle of audits. These audits include gathering information from residents and staff, they also include a homes’ self-assessment. Other information is also gathered from stakeholders such as Social Services. The annual review does report upon the homes successes and areas of improvement. The last annual review available was for year end 2005 and it included an action plan. The cycle of reviews for 2006 has been completed and the annual review is due shortly. Residents are having regular meetings and discussing topical issues such as the seasonal menu, activities, festivities and they have been invited to help review the homes policies. The senior managers often visit the home and produce a report, this includes meeting residents and staff, viewing areas of the home and checking operations. Concerns raised by the inspector about the environment had not been identified in the reports. Records of staff supervision were seen, these meetings are frequent and often the agenda would include roles and responsibilities, training and development and also a self-assessment. The home had a recent visit by the environmental health, which mainly focused upon food safety and hygiene. The report was very positive and indicated many good practices. Equipment used at the home including for example hoists, emergency call and fire equipment are regularly serviced and maintained. The fire system is regularly serviced and tested including the alarm and emergency lights as are utilities such as gas, electric and water, which have been checked and certified for safety. The most recent passenger lift inspection could not be found at the time of inspection, however there were records of maintenance of the passenger lift. The home completes a monthly health and safety inspection, which is extensive and covers many areas, as identified earlier it was a concern that it did not identify improvements needed to the environment. The home has developed many risk assessments; these include fire safety, COSHH, workplace risks and hygiene and infection control. The home does provide a service for the residents to deposit small amounts of money; this is mainly deposited by the relatives of the residents. However for four residents the Social Services arrange for their money to be delivered to the home. The inspector was advised that soon this would stop and an account would be needed for this money to be paid into. How this is to be Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 23 managed is being planned by the home and senior managers. Records, receipts and balances were checked for four residents and found to be accurate, however all transactions should be witnessed and recorded. Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 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 3 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 3 17 X 18 1 2 3 3 3 X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 2 2 Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 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 OP3 Regulation 14(1)(a,b) Requirement The registered person must ensure that very important information about the resident be available to them, including a full assessment of their needs before they accept residents on an emergency basis. The registered person must ensure that all staff are skilled and experienced to meet the needs of residents. Previous timescale of 30/06/06 not met, this requirement is carried forward. 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 they contact a GP for review of medicines and consider any required pain DS0000004520.V314832.R01.S.doc Timescale for action 20/12/06 2 OP4 12(1) 18(1)(a) 31/03/07 3 OP8 12(1) 20/12/06 4 OP8 12(1) 29/11/06 Silverbirches Version 5.2 Page 26 5 OP8 6 OP8 7 OP9 8 OP12 9 OP15 10 OP15 OP27 relief. (For one named resident, as issued on the immediate requirement form at the time of inspection). 12(1) The registered person must 13(4) provide risk assessments with 15(1) management plans that staff can fully implement including; a) Risk of wandering into other residents’ rooms. b) Refusing personal care. c) Not sleeping. d) Mobility. e) Impact on movement due to fractured arm. (For one named resident, as issued on the immediate requirement form at the time of inspection). 12(1) The registered person must 13(4) ensure that where a risk 15(1) assessments requires staff monitor indicators that these indicators are made known to staff and recorded within risk management plan. 13(2) The registered person must ensure that stocks of medication are accurate and residents receive their prescribed medication. 12(1) The registered person must 16(2)(m,n) ensure that residents are offered to take part in opportunities of their choice, appropriate records must be maintained. 12(1)17 The registered person must (2) Sch ensure that the food and fluid 4(13) charts are signed as per the homes protocol by senior care staff and any concerns are recorded with action taken. Not fully assessed and is carried forward. 18(1)(a) The registered person must 12(1) ensure that there are adequate amounts of staff to assist DS0000004520.V314832.R01.S.doc 30/11/06 31/12/06 20/12/06 20/12/06 31/12/06 20/12/06 Silverbirches Version 5.2 Page 27 11 OP18 12(1) 13(6) 12 OP18 OP30 18(1)(c) (i) 13(6) 13 OP19 23(2)(b,c, d) 14 OP19 23(2)(b,c, d) 15 OP26 23(2)(d) 16(2)(k) 16 OP27 18(1)(a) 17 OP30 18(1)(c) (i) 18 OP31 CSA 2000 residents where needed at mealtimes. The registered person must ensure that incidents in the home are appropriately reported to the Social Workers and where necessary raise their concerns under Adult Protection policy. The registered person must ensure that all care staff receive training about protecting vulnerable adults and abuse, this must include recognising it and their responsibilities. The registered person must ensure that a programme of refurbishment and redecoration is identified and that work is undertaken as per programme to improve communal areas of the home. The registered person must ensure that communal areas of the home that require urgent attention and present a risk to residents are improved and made safe. The registered person must ensure that untoward odours are effectively managed and that all parts of the care home are kept clean. 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. All staff must receive training in safe working practices; this must include fire safety training, food hygiene and infection control. The registered person must make an application to register a manager with the CSCI. Previous timescale of DS0000004520.V314832.R01.S.doc 20/12/06 31/01/07 30/06/07 20/12/06 20/12/06 30/06/07 31/01/07 31/01/07 Silverbirches Version 5.2 Page 28 19 OP38 23(1)(a)13 (4)(a) 30/11/05 not met, this requirement is carried forward. The registered person must ensure that the remedial work as identified in the latest lift service report is completed. A copy of the most recent report must be forwarded to the commission 31/12/06 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 OP35 Good Practice Recommendations It is recommended that samples of food prepared and cooked are maintained for at least five days. Not assessed and is carried forward. It is strongly recommended that all records of how the money of residents is managed is always witnessed and the record be signed by the witness. Silverbirches DS0000004520.V314832.R01.S.doc Version 5.2 Page 29 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.V314832.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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