Inspection on 06/09/05 for Silverbirches

This inspection was carried out on 6th September 2005.

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 29/11/06

Silverbirches 15/05/06

Silverbirches 10/02/06

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 Silver Birches 23 Tyne Close Chelmsley Wood Birmingham B37 6QZ Lead Inspector Sean Devine Announced 6 September 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Silverbirches Address 23 Tyne Close Chelmsley Wood Birminggam B37 6QZ 0121 788 3758 0121 788 3956 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Accord Housing Association Vacant Care Home 50 Category(ies) of Dementia - Over 65 (15) Old Age (35) registration, with number of places Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can admit one named Service User (CH) aged 61 years. 2. Can admit one named Service User (CS) aged 62 years. Date of last inspection 29 March 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. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted on an announced basis over a period of one day. A new manager is currently working a trial period under supervision of the previous registered manager. The temporary manager will depending on a successful trial period apply to the commission for registration. The inspector had opportunity to meet with residents and tour the home. Records pertaining to the service and to care provisions were seen, staff were interviewed on an informal basis. What the service does well: What has improved since the last inspection? What they could do better: Further improvements are needed in care planning and risk assessing, care plans need to be reviewed more frequently. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 6 Staff require further training and frequent supervisory support to ensure that their practices are safe at work and that they have the competencies to undertake their roles and responsibilities. There is a need to improve the management of medication, to ensure that it is safe for residents and that they receive all prescribed treatment. 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. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 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 standard(s) 1,3,4 Appropriate information is available and assessment of prospective residents is completed, this enables prospective residents to make a fully informed choice and for the home to be assured that they can meet the residents needs. EVIDENCE: The residents guide and statement of purpose are fully reflective of the services and resources available at the home. These documents, which are regularly kept updated are available for prospective residents and their representatives. Sampled residents files contained pre-admission assessment information and also details gathered by the home on admission. The assessments completed since admission were extensive, including health and medical matters, information and routines and personal care needs. A section for life histories is available, however this information was found to be limited and incomplete for some residents. The home is planning some redecoration on Kingfisher Unit, the manager advised that consultation with Accord Housings dementia consultant will take Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 9 place to ensure décor is suitable for residents with a dementia. The staff team organise a range of appropriate activities to meet the diverse needs of residents. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The health and social care needs of residents are adequately met; the residents have access to required services, which means they are supported quickly and effectively. Certain aspects of medication practice must be improved to ensure it is safe and free from risk to residents. EVIDENCE: Residents are provided with a written care plan that describes how all their assessed needs are to be met by the home. The care planning process does need to be improved to ensure that this description is fully informative for staff, that these plans are reviewed regularly and that the review describes how effective or not the plans have been. One resident who has recorded episodes of aggressive behaviour did not have a written care plan or specific risk assessment. Sampled residents files did not include a risk assessment to identify the nutritional and tissue viability needs of residents which must be completed if a risk is identified, however all sampled files did have a manual handling assessment, a food and diet assessment and a record of monthly weights. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 11 Records that reflect that residents have access to required community healthcare facilities were available and upto date. The medicine policy is informative for staff guiding them in the safe management and administration of medicine and includes guidance on selfmedication for residents. There are improvements needed to include: • • • • • Ensuring there are no gaps on medication administration records (MAR) other than for as required medicine. Ensuring accurate stocks of medicines are maintained. Recording receipt of all medicine on the MAR. Disposing of creams and ointments after 28 days. Recording the date creams and ointments when opened. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 The daily life and social activity needs of residents are met, this means residents are provided with a stimulating and fulfilling day based upon their assessed needs. EVIDENCE: Assessments of social and leisure needs are completed, when needs are identified a written care plan is developed. The social and leisure activity of residents is recorded on a daily basis. At the time of inspection an external entertainer was performing in the home. Planned activities are well advertised and include for example: a church service, film club and progressive mobility sessions. Visitors were seen to visit residents and use the residents’ rooms during this period; some relatives were supported discreetly by staff when assistance was needed. The residents are invited to a monthly meeting; records of the meetings include briefings of changing and new policies, raffles and a review of the food menu with the kitchen staff. Further consultation is needed with residents or their families in respect of care planning. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 13 Food is prepared at the home, the kitchen was clean and hygienically maintained. Storage, preparation and cooking areas are mainly safe. Improvements needed include labelling all food items in freezer and fridges and ensuring a schedule and record of deep cleaning is in place. During the lunchtime on Kingfisher Unit some residents were seated in the dining area and some in the quiet lounge. Staff were supportive to residents and clearly were aware of their nutritional needs, two residents were seen to have a special diet. Two residents who were reluctant to eat had their meals put back in the heated trolley. Minor improvements needed include: having menus available for residents to see, ensuring the notice board is kept upto date (as it indicated breakfast meal not lunchtime) and also ensuring residents are provided with condiments. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,19 Residents concerns and safety is adequately managed and advocated for, this means residents are afforded appropriate support in improving areas of concern and also protected through staff knowledge and competency. EVIDENCE: A concerns, complaint and compliments procedure is available for staff; this includes a form for a complainant to raise areas of concern. The complainant is given an option if unsatisfied to raise the complaint at a higher level. A complaints record is maintained at the home, which is completed in line with the procedure. Recent complaints have been effectively managed. The procedure needs to be updated to include current details of the CSCI office. The manager has raised concerns where appropriate using local authority adult protection guidelines, including consultation with social workers, police and CSCI. Many staff have received adult protection training, further training will continue as this is included within Accords training programme. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) all standards. Individual rooms are complimentary of the needs of residents and encourage a great degree of independence and promote safety. The environment in some communal areas is not altogether hygienically maintained to meet the health and safety needs of residents, however other communal areas were clean, pleasant and comfortable. EVIDENCE: Three separate units provide well maintained accommodation to residents; Kensington Unit has 15 rooms for residents with dementia, Robin Unit and Jay Unit, 18 and 17 rooms respectively for residents requiring residential accommodation. All residents’ rooms have en-suite toilet facilities. Communal areas such as gardens and dining rooms are spacious and well maintained. It is evident that a routine programme of maintenance and refurbishment is in place. The manager advised of the improvements planned for Kensington Unit to include décor and carpets, this was of specific concern due to odour management issues, which was permeating throughout the unit. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 16 There are four fully assisted shower rooms and four assisted bathrooms, which are large and spacious to meet the needs of residents. There are also a number of communal toilets. The first floor is accessible via a passenger lift, all corridors and doorways are wide, all areas of the home are accessible for wheel chair users and safety rails are appropriately sited throughout. Some residents rooms were viewed, they were large a clearly provide ample space; storage areas and furnishings are of modern design. The heating and lighting was adequate with a good degree of natural lighting from the windows. All rooms seen had been personalised by residents and relatives, with the support of the home. Some residents had telephones within their rooms. The laundry area has a dirty side and a clean side to help reduce the spread of infections and there is a clinical and sanitary waste contract in place. All highrisk areas have appropriate hand washing facilities. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) all standards. The recruitment practices and staffing levels are adequate to ensure the safety and care needs of residents can be met. Some staff have not received basic training to ensure that the needs of all residents will be met in a skilled and effective manner. EVIDENCE: Adequate numbers of care assistants are allocated to all three units between 7.45 am and 9.45 pm. The care is overseen on all three units by a minimum of two senior care assistants and at night one care assistant works on each unit supported by a one senior care assistant in the home. Both manager and the deputy are supernumerary to care staff. Ancillary support including cooks and domestics are employed in adequate numbers to provide this specific service. There are currently four care staff vacancies, these hours are covered by the homes staff with some hours allocated to agencies to cover. The manager maintains a training matrix, the most current matrix records that a mixture of fourteen (14) senior care assistants and care assistants have completed NVQ awards at level 2,3 or 4. There are thirty-five care staff employed and four vacancies, which means that 36 of staff have achieved the award. The training matrix identifies a range of induction and specific service training for example, equal opportunities, care for the dying, dementia training, basic Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 18 food hygiene, fire safety, health and safety emergency aid, moving and handling, medication training, adult protection and COSHH. All areas are covered with an organisational training programme. It is evident that some staff are yet to complete some areas of induction and service specific training. It is of concern that some staff have not received fire safety training which should be completed on an annual basis whilst attending a minimum of two fire drills. Staff recruitment files were sampled; all included required checks such as criminal records bureau disclosures and two written references. Application forms and interviews are completed and conducted respectively and prospective new employees complete a medical screening. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,35,36,38 The management and administration of the home is not fully adequate to ensure the health and safety of residents and staff. Supervision arrangements and some requirements made by the fire service have not been addressed posing a potential risk for residents’ health, safety and well-being. EVIDENCE: The current manager advised the inspector she was on a trial period and that she is to commence NVQ 4 in Management and Care. Since inspection the CSCI have been advised by the Head of Service that the manager commenced this training in September 2005. She had also been the deputy manager at the home for sometime, several residents positively commented on her ability as manager and as a friendly person. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 20 Residents and staff meet on a monthly basis to discuss changing policies, new developments, topical issues and areas of improvement, this is co-ordinated by the manager. The manager oversees a system to safeguard residents’ money in the home, at the time of inspection transactions and balances were found to be accurate, however some recent receipts to confirm transactions could not be found. Since the inspection the manager has confirmed these receipts have been found. All other receipts were available. The manager co-ordinates a system of staff supervision: senior care assistants supervise care staff, the deputy manager supervises the senior care staff and the manager supervises the deputy manager. The training records do not record supervisory management of staff, this training is recommended for staff without management experience and qualifications. There is a supervision programme, which is signed by the supervisor when completed and the supervisee signs a contract. Records suggest that staff do not have supervision at a frequency that provides them with adequate support. The manager has recently been involved in the review of risk assessments pertaining to staff, building, food and fire. These risk assessments clearly record measures to reduce the identified level of risk. The fire system is frequently tested and serviced at required intervals, staff do attend fire drills, however it is clear from records that not all staff attend twice a year. The manager must ensure that the recommendations made by the fire officer at his visit on the 28th July 2005 be fully implemented including fitting free swing self-closing devices to certain doors. Other sampled health and safety checks that are kept upto date include the service of lifts, gas appliances, hoists and electrical items. The manager completes a monthly audit of accidents, she advised this is done to ensure that early indicators of trends are identified and then where possible risks removed. Records suggest staff have acted appropriately including the provision of first aid, contacting GP / emergency services or monitoring and observation. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 x x 3 2 x 2 Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 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. The registsred person must ensure that care plans especially in respect of personal care describe to staff how they specifically support individual residents e.g. grooming, dressing, bathing. 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. 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. The registered person must ensure that gaps on the medication administration records are investigated and corrective actions taken. That all creams and ointments Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 23 Timescale for action 31/10/05 2. OP7 15(2)(b) 31/10/05 3. OP8 12(1) 31/10/05 4. OP9 13(2) 7/9/05 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. 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. The registered person shall ensure that odour management is maintained in all areas of the home in particular on Kingfisher Unit. Previous timescale of Mid June 2005 not met, this requirement is carried forward. The registered person shall ensure that 50 of care staff employed have achieved a minimum of NVQ level 2 or equivalent. The registered person must 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. The registered person must make an application to register the current manager with the CSCI. The registered person must ensure that staff are provided with frequent supervision in line 31/10/05 31/10/05 5. OP15 16(2)(i) 31/10/05 6. OP26 16(2)(c )(k) 9/9/05 7. OP28 18(1)(c )(i) 31/3/06 8. OP30 18(1)(c 0(i) 31/12/05 9. OP31 CSA 2000 30/11/05 10. OP36 18(2) 30/11/05 Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 24 11. OP38 23(4)(e) with national minimum standards. 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. 31/10/05 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 responsibilites with appropriate training. Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Birmingham & Solihull Local 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 Silver Birches E54_S4520_Silverbirches_V230566_ai_060905_Stage 4.doc Version 1.40 Page 26 - 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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