Inspection on 28/07/08 for Briardene Unit - South View Care Home

This inspection was carried out on 28th July 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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Briardene Unit - South View Care... 31/07/07

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE South View West Avenue Billingham Stockton-on-Tees TS23 1DA Lead Inspector Sue Lowther Key Unannounced Inspection 28th July 2008 10:00 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 South View DS0000069202.V369190.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. South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South View Address West Avenue Billingham Stockton-on-Tees TS23 1DA 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) 01642 530971 01642 521811 southview@barchester.net www.barchester.com Barchester Healthcare Homes Ltd Manager post vacant Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52), Physical disability (7) of places South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 52 2. Physical disability - Code PD, maximum number of places: 7 The maximum number of service users who can be accommodated is: 52 31st July 2007 Date of last inspection Brief Description of the Service: South View is registered to provide personal and nursing care to fifty-two older people. The home is situated on West Avenue in Billingham and is close to shops and amenities. The care home consists of two separate buildings, which have been named Hazledene and Briardene. Hazledene can accommodate a maximum number of twenty-four residents requiring personal care, however the acting manager told the inspector that this part of the building is no longer used. Briardene can accommodate a maximum number of twenty-eight residents requiring nursing care. Bedrooms are single in nature, however, not all meet space requirements of National Minimum standards. One of the bedrooms has ensuite facilities, which consists of a toilet and hand washbasin. There is a passenger lift giving access to both floors. There is a lounge and a dining room. South View is set in grounds, which are accessible to residents, and provides car-parking facilities for visitors. The cost of care at the time of the inspection visit (depending on the category South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 5 of care) ranged from £416 to £685 per week. This does not include hairdressing, chiropody, newspapers and personal toiletries. South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection of South view Care Home took place on the 28th July 2008. Records were examined and a tour of the building took place. Time was spent talking to people living at the home, staff and visitors. The manager supplied some information prior to the inspection on a form called an AQAA. This is an annual quality assurance assessment for home’s to provide information about their service. The inspection focussed on key standard outcomes for people living at the home. We also checked whether requirements from the previous report had been met. What the service does well: What has improved since the last inspection? There was evidence to confirm that all of the requirements and recommendations highlighted in the last report have been met. Care plan evaluations are now comprehensive and include detail of changes in condition. This makes sure that all of the needs of the people who live in the home are met. South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 7 All staff have received an update on the administration of medications and medicines are no longer pre-potted. This is to reduce the risk of a mistake being made. The complaint’s procedure has been updated so that people have all of the information they need about how to make a complaint. The toilet flooring has been replaced where needed. This is to make sure that it can be cleaned properly to prevent the risk of cross infection. The acting manager has carried out a review of staffing levels to make sure there are sufficient staff on duty to meet all of the needs of the people who live in the home. The acting manager has applied to be registered with the CSCI. Bath water temperatures are now checked on a weekly basis to make sure that they are maintained at a safe level. What they could do better: 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. The summary of this inspection report can be made available in other formats on request. South View DS0000069202.V369190.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 South View DS0000069202.V369190.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. People who use the service experience good quality outcomes in this area. Assessment procedures are in place to ensure that the home can meet the needs of the people who live there. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: People are only admitted after a full assessment of need is carried out by an appropriately trained person. This is usually the acting manager. This is to make sure that the home can meet the care needs of the people who go to live there. The family of one person who had recently gone to live in the home confirmed that they had looked around the home and had been supplied with all of the information they needed to make a decision about whether or not their relative would like to live there. The people who responded to the survey said that they had received enough information about the home before they went to live there. One person said, “I was allowed to visit before I made the decision to come and live here”. South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 10 The home does not admit people for intermediate care therefore assessment of standard 6 is not required. South View DS0000069202.V369190.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People who use the service experience good quality outcomes in this area. People’s health care needs are well managed by the home. Systems to administer medication are safe and people living at the home say that they are treated well and that the standard of care is good. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The acting manager said that all of the people who live in the home have care plans so that staff know how to look after people on an individual basis. Three were examined during the inspection. These were comprehensive and contained individual plans of care. The evaluations now contain information about improvements or deterioration with regard to specific problems. This was a recommendation in the last inspection report. People spoken to during the inspection and those who returned surveys said that they are generally happy with the care received and the level of South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 12 information given. One relative said, “The staff are always willing to help and respond to any questions. I am always informed about any changes”. Records examined showed that people receive visits from other healthcare professionals. These include district nurses, doctors, and care managers. One health care professional who returned a survey said, “The home provides a high standard of general nursing across a variety of conditions and needs. The staff are adaptable, flexible, considerate and caring”. Medication is administered by qualified nurses . The home has a comprehensive medication policy. Accurate records of all medicines received, administered and those leaving the home are maintained. However one medication which had a limited shelf life once opened did not have the date of opening identified on the bottle. Whilst it is accepted that this could not be out of date, due to the date it was dispensed, it is recommended that the date of opening be identified on the bottle to prevent error. The last inspection report contained a requirement about the admimistration of medication. This was about the pre potting of medication which the inspector had seen taking place. The acting manager said that all staff have had an update with regard to the administration and are being closely monitored with regard to this. People spoken to said that staff always treat them with dignity and respect. South View DS0000069202.V369190.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience excellent quality outcomes in this area. The activities are varied and provide recreation for some of the people who live in the home. Family and friends can visit at any time and are made to feel welcome. The meals are of a good standard. Menus are varied and people are given a choice. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home employs an activities organiser. She told the inspector that she tailors her activities to cater for people’s wishes as far as possible. Regular activities include bingo, quizzes, manicure and pamper days and trips out for lunch and to local attractions. Outside entertainers also come into the home on as regular basis, the most recent one being a line dancer. All of the people who returned surveys were satisfied with the activities on offer. People spoken to during the inspection confirmed that family and friends can visit at any time and are made to feel welcome. One person said, “The staff South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 14 always speak to my family when they visit. They usually offer them a cup of tea”. People confirmed that they are given a choice about how they wish to spend their day. One person said, “Residents can go to bed at a time to suit them and are always asked if they are ready to get up in the morning. They are taken to sit outside on warm days if they wish. Different denominations visit to bring Holy Communion to residents who wish to receive it”. Comments about the food were good. This looked appetising and people said that it was tasty. Specialist diets are catered for and include menus for diabetics and soft menus. Staff said that there is a four weekly rotation of the menu, but that the cook looks at the menu everyday and caters to individual choice where possible. Two people who returned surveys said that they usually liked the meals on offer. Staff were seen to offer assistance to people in a discreet and dignified manner. South View DS0000069202.V369190.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People who use the service experience good quality outcomes in this area. The people who live in the home can be confident that their concerns and complaints are dealt with appropriately and sufficient safeguards are in place to protect them from abuse. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Information about complaints, how and who to make them to, is made available to the people who live in the home and their families through information displayed in the entrance to the home and in the ‘Service Users Guide’. The last inspection report recommended that the Complaints policy/procedure should be updated to include information of residents’ rights to complain to commissioning agencies such as Social Services and the Primary Care Trust. The home’s statement of purpose and service user guide should also be updated to reflect such information. The acting manager confirmed that this had been done. There one complaint recorded since the last inspection. This was dealt with using the home’s own procedure. All of the people who returned surveys confirmed that they know how to make a complaint. One person said, “If I had a problem I would tell the staff, but things are usually sorted without making a formal complaint”. The home had a comprehensive adult protection procedure. This gives staff the support they need to make a referral should this be required. The staff spoken South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 16 to during the inspection were asked about abuse and what they would do if they saw or heard anything inappropriate. All said that they would tell someone, for example the manager, or make a referral themselves if this was more appropriate. Training is provided for all staff in adult protection. One member of staff said, “I would have no hesitation in reporting any concern. I am here for the residents”. Another said, “I would always report anything straight away”. South View DS0000069202.V369190.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. People who use the service experience good quality outcomes in this area. The home is clean and well maintained. It is decorated and furnished to a good standard and provides a homely environment for the people who live there. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: During a tour of the building the inspector saw that many of the rooms are decorated to the person’s own taste and there was evidence to confirm that people can take in some personal items when they go to live there. This includes pieces of furniture as well as photographs and ornaments. There was a range of equipment seen around the home to support people with bathing and mobility. South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 18 The last inspection report contained one requirement about the environment. The floor covering in the toilet on the ground floor of the nursing unit required replacement to ensure floors could be cleaned and to prevent the spread of infection. The acting manager confirmed that this had been done. The inspector found the building to be clean, tidy and free from offensive odours. South View DS0000069202.V369190.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People who use the service experience good quality outcomes in this area. The home has a settled and well-led staff team, in sufficient numbers to meet the needs of the people who currently live in the home. Training is provided for all staff. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: From the rota supplied at the inspection there was sufficient care staff on duty to meet the assessed care needs of the people who were using the service. People said that staff were usually around and answered the call bells quickly. The last inspection report required that an assessment of residents be carried out to determine if there are sufficient staff on duty to meet the needs of the residents residing at the home. Most of the people who returned surveys felt that there are sufficient staff on duty. However one person said, Staff are often busy and are not able to react as quickly as I would like”. The acting manager confirmed that staffing levels are constantly being reviewed to make sure that they meet the changing needs of residents. The home had staff files in place, which provided evidence that the appointment of a new staff member is made through proper recruitment processes. This includes the vetting of staff through the use of references, POVA first checks and Criminal Record Bureau (CRB) checks. South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 20 There is a commitment at the home to having a trained workforce with many of the staff having an NVQ at level 2 or above. Training is provided for staff. As well as mandatory training, recent training has also taken place in adult protection and health and safety, moving and handling, first aid, nutrition and control and restraint. Staff said that they are also supported with regard to personal training needs. Staff comments in this area were positive. Comments included “My induction covered everything that I needed to know about my job role, also mandatory training is done every time it is needed.” Another said, “My manager is very supportive and helps me to progress further within my role at work.” South View DS0000069202.V369190.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People who use the service experience good quality outcomes in this area. The home’s acting manager provides clear leadership, support and guidance to those living and working at the home. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The acting manager has worked in the care home environment for several years. She has a diploma in management and an advanced management qualification in care. She has applied to be registered with the CSCI. This was a requirement in the last inspection report. There was an open and friendly culture between the management team and staff working at the home. There was evidence in staff files to show that South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 22 supervision was taking place and that the staff were being appraised. Staff confirmed that supervision takes place on a regular basis and that they are well supported. People living at the home and visitors who were spoken to during the inspection confirmed that the manager is approachable and that they would go to her if they had any concerns. One staff member said, “We have an excellent manager. She respects and appreciates the hard work the rest of the workforce do from carers to kitchen staff and domestics”. Regular meetings are held and the company have a number of systems in place to consult with people living at the home. The manager confirmed that monthly Regulation 26 audits by the owner take place. Customer satisfaction surveys have also taken place and the manager said that comments are acted on and improvements made wherever possible. The home does not hold personal allowances on behalf of the people who live in the home. The home purchase items and pay for services that people request. Where these are not included in the fees, the cost is added to the monthly bill. The acting manager confirmed that all equipment in the home is regularly checked. The maintenance certificates that were seen at this inspection were found to be in order. The last inspection report recommended that the Registered Person should give consideration to the Health and Safety Executive Guidelines to monitor bath and shower water temperatures weekly. The acting manager said that this was now being carried out. South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP1 Regulation 39 Requirement The Registered Person must advise the CSCI in writing with regard to the plans for the Hazeldene Unit. Timescale for action 30/09/08 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 OP9 Good Practice Recommendations Medications that have a limited shelf life once opened should have the date of opening identified on the label. This is to avoid the risk of error. South View DS0000069202.V369190.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 South View DS0000069202.V369190.R01.S.doc Version 5.2 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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