Inspection on 31/07/07 for Briardene Unit - South View Care Home

This inspection was carried out on 31st July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Briardene Unit - South View Care... 28/07/08

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

CARE HOMES FOR OLDER PEOPLE South View West Avenue Billingham Stockton-on-Tees TS23 1DA Lead Inspector Katherine Acheson Key Unannounced Inspection 31st July 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address South View DS0000069202.V345202.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.V345202.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 Barchester Healthcare Homes Ltd 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.V345202.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 7 service users under the age of 65 can be admitted within the PD Category of registration. 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 and 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 fifty-two bedrooms has ensuite facilities, which consists of a toilet and hand washbasin. There is a passenger lift in both buildings giving access to all floors. lounge and a dining room in each building. There is a 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 of care) ranged from £327 to £619 per week. South View DS0000069202.V345202.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on 31st July 2007 and lasted for seven hours. The reason for the inspection was to see how good a job the home does in meeting the National Minimum Standards set by the government for Care Homes. A new Manager has been appointed to work at the home and was present for a short part of the inspection. Six residents, one relative, two Care Assistants and the Office Administrator were spoken to during the visit. A lengthy discussion also took place with the Deputy Manager. Numerous records including care plans, menus, recruitment and training records were examined. complaints and staff The Inspector walked around the home with the Deputy Manager. The details of any issues identified at this inspection requiring action are to be found at the back of this report. Before the inspection fifteen comment cards for residents and fifteen comment cards for relatives were sent to the home for the Manager to distribute accordingly. Comment cards requested feedback on the service and staff provided. Four resident and one relative comment card were returned to the Commission for Social Care Inspection. Comments received can be read within the report. What the service does well: The home provides a good standard of care. Residents are happy with the care provided and staff are appropriately trained. Care plans are detailed, which will help to ensure that resident’s needs are met. Appropriate and enjoyable activities and outings take place. Resident’s benefit from having the use of a minibus. Food provided is good and enjoyed by residents. South View DS0000069202.V345202.R01.S.doc Version 5.2 Page 6 Residents and relatives comments received in respect of the home included, “The care and help in general is very good. The laundry service is good and cleanliness is excellent”. “I think it is very good I am quite happy here”. What has improved since the last inspection? 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.V345202.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection South View DS0000069202.V345202.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of prospective residents are carried out to ensure that the home can meet their needs. EVIDENCE: Before going into South View, residents are assessed by a Social Worker or health care professional. A copy of this assessment is forwarded to the management of the home so that a judgement can be made to see if needs can be met. Staff at the home then carry out their own pre-admission assessment either visiting the person in their own home or at hospital to ensure that the needs of the resident can be met at South View. South View DS0000069202.V345202.R01.S.doc Version 5.2 Page 9 The Deputy Manager said that before going into the home, prospective residents could spend time at the home and stay for lunch or tea. Two residents files were looked at during the visit, both of which contained a detailed assessment of needs and evidence of personal choice. South View does not provide intermediate care so standard 6 is not applicable to this home. South View DS0000069202.V345202.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of care. Care plans are detailed, which will help to ensure that resident’s needs are met. Improvements are needed in respect of medication practice to avoid errors. EVIDENCE: Two plans of care were looked at during this visit both of which contained detailed information about the resident and the help they needed. Assessments were informative. Likes, dislikes and personal preferences were recorded and care plans showed clear evidence of choice. Care plans contained signatures to confirm that they had been drawn up with and reviewed by residents and relatives. South View DS0000069202.V345202.R01.S.doc Version 5.2 Page 11 Care plans showed evidence of regular visits from G.P’s, District Nurses, Dentists, Opticians and the Chiropodist. Care plans were evaluated on a monthly basis, however did not comment on any deteriorations or improvements made. A discussion took place with the Deputy Manager in respect of this who said that she would take action to address the situation. Residents are treated with respect and their privacy and dignity is maintained. Care staff spoken to during the visit were able to give examples of how they treated residents with respect whilst ensuring privacy and dignity. Care staff demonstrated an in depth knowledge of the people they were caring for. Six residents, three at length and three briefly, and one relative were spoken to during the visit, comments made included, “They do look after me well” “The staff are good” “I think it is very good, I am quite happy here. Staff are very good, on the whole very obliging” “They do the best they can” Comment cards received stated, “We as a family are very pleased with South View” “Staff are very helpful. Nurses are excellent” “I am treated with care and respect” “They are lovely and kind” During the inspection arrangements for receiving, storing, administering, recording and disposing of resident’s medication were observed and examined. The Deputy Manager said that Nurses give medication to residents on the nursing unit and designated care staff give medication to residents on the residential unit. The Deputy Manager said that care staff who give medication to residents have all received appropriate training. Each unit within the home has their own medication room. inspection the medication room within nursing unit was visited. During this South View DS0000069202.V345202.R01.S.doc Version 5.2 Page 12 A medication audit of one resident was carried out. Medication Administration Charts (MAR) had been completed correctly and the stock balance of medication belonging to the resident was correct, matching up with medication ordered, received, administered and remaining in the home. Whilst talking to one resident on the nursing unit the nurse came into give lunchtime medication. At this point the Inspector noticed that the nurse had a number of other residents medication pre-potted up and ready to give to other residents on the nursing unit. This is not acceptable practice. A brief chat took place with the nurse in respect of this. Each individual residents medication must be given one at a time to avoid errors. South View DS0000069202.V345202.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): Standards assessed 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate and enjoyable activities do take place at the home. Visitors are encouraged and made to feel welcome at anytime. Food provided is varied, appetizing and appealing and provides residents with a wholesome balanced diet. EVIDENCE: The home employs an Activity Co-ordinator to plan, arrange and take part in resident activities. The Activity Co-ordinator works thirty-seven and a half hours a week and spends time on both the residential and nursing unit. The Deputy Manager advised that time is also spent on a one to one basis with those residents who are less able. Activities taking place include bingo, dominoes, quizzes, and arts and crafts. South View DS0000069202.V345202.R01.S.doc Version 5.2 Page 14 Resident activities are planned for the week ahead and displayed throughout the home. The home employs a driver and has a minibus, which is used to take residents on hospital appointments, GP visits and on outings. Recent trips out have included Hartlepool Marina, Crimdon Dene and Redcar. Contact with family and friends is encouraged and that visitors are made to feel welcome at any time. Residents and the one relative spoken to and comment cards received stated, “I enjoy the trips out in the mini bus for an ice cream” “I enjoy my own company, I like to read magazines and do crossword puzzles” “A daily programme is arranged” “There is a lot of entertainment, I always go to see the singers” “I would like to go out for more walks, I have asked but they don’t take me” “Sometimes we bake cakes”. A number of residents were observed to be enjoying the afternoon sun. Numerous tables, chairs and benches are available at the front of the home for residents to sit out. The Deputy Manager said that the home supports residents to practice their religion. A special Minister visits the home at least once a week to give any catholic residents communion. Residents interviewed spoke of flexibility in routine and freedom of choice. The lunchtime of residents on the nursing unit was briefly observed. Mealtime was relaxing with residents enjoying the food provided. Food served was well presented. Staff were sitting and helping those residents that required support or feeding at mealtime. Residents spoken to said, “The food is good there is choice. I am putting weight on because I eat that much” “The food is very good you get two choices. I had barbeque pork loin today, the other option was steak and ale pie” “All vegetables are fresh”. South View DS0000069202.V345202.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): Standards assessed Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are able to express their concerns. Staff are aware of procedures to follow if abuse is suspected which helps to protect residents. EVIDENCE: The home has a complaint procedure. This procedure should be updated to inform residents/relatives of their right to complain to any commissioning authorities such as the Primary Care Trust or Social Services. The complaint procedure within the statement of purpose/service user guide should also to be updated to include such information. Residents spoken to during the inspection said that they would feel comfortable in raising and concern or making a complaint to the staff or management of the home. The home keeps a record of complaints. There have been five complaints made to the home since the beginning of February 2007. South View DS0000069202.V345202.R01.S.doc Version 5.2 Page 16 The home has an adult protection policy and a copy of the Teeswide Guidance regarding the protection of vulnerable adults. Adult protection training is provided to staff working at the home. There has been one adult protection referral since the beginning of February 2007. South View DS0000069202.V345202.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): Standards assessed 19, 21 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing residents with an attractive, homely and comfortable place to live. EVIDENCE: During the visit a walk round of the home took place. The home can accommodate a maximum number of fifty-two residents. There are two separate buildings on one site. Hazledene can accommodate a maximum number of twenty-four residents who need personal care and Briardene can accommodate twenty-eight residents needing nursing care. South View DS0000069202.V345202.R01.S.doc Version 5.2 Page 18 In general the home is well maintained. Lounge and dining room areas are pleasantly decorated and bedrooms are personalised. During the walk round of the home it was noticed that a toilet on the ground floor of the home on the nursing unit needed the flooring replaced. The position of the toilet had been changed leaving a hole in the flooring. The home has a policy in respect of control of infection. Staff spoken to during the inspection said that there was always a plentiful supply of protective clothing. Appropriate laundry facilities are in place. South View DS0000069202.V345202.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): Standards assessed 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff at the home are trained and skilled to meet the needs of people living at the home. EVIDENCE: At the time of the inspection there were nineteen residents residing on the residential unit and nineteen residents residing on the nursing unit. Duty rotas examined confirmed that on the residential unit there is three care staff on duty throughout the day one of which is a senior carer. On night duty there is one senior carer and a care assistant. On the nursing unit there is two qualified nurses on duty on a morning, one on an afternoon and evening. In addition there are three to four care staff on duty from 8:00am until 6:00pm and three care staff on duty 6:00pm until 8:00pm. On night duty there is one qualified nurse and two care staff on duty. South View DS0000069202.V345202.R01.S.doc Version 5.2 Page 20 The Manager of the home is employed to work five days supernumerary a week. A few comments were made by residents and relatives during the inspection and on comment cards received stating that they did not feel that there were always sufficient staff on duty. Comments made included: “I don’t think that there are enough staff on duty particularly at the moment at holiday time” “I don’t think there are enough staff on duty” “Need more staff! To help existing staff to carry out their duties”. A discussion took place with the Deputy Manager in respect of this who advised that residents on the nursing unit are very dependant on care and nursing staff. A discussion took place regarding the need to carry out an assessment of residents to determine if there is enough staff on duty. 57 of care staff working at the home have now achieved an NVQ level 2 in care. The homes recruitment procedure is robust. The files of two newly appointed staff were looked at during the visit. Evidence was available to confirm that appropriate Criminal Record Bureau checks are carried out before staff start working at the home. Files examined contained all of the required information including, proof of identity and two references. Records were evidenced to confirm that all newly appointed staff receive induction training; the Deputy Manager said that this has recently been updated to meet with current induction standards as set by Skills for Care. Records were available to confirm that regular training is provided to staff working at the home, this included, Moving and handling, fire, abuse training, catheter care and food hygiene. South View DS0000069202.V345202.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): Standards assessed 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general the health and safety of residents is promoted. Quality assurance systems are in place to ensure that the home is run in the best interest of residents. EVIDENCE: A new Manager has been employed to work at the home, the Manager is aware of the need to apply to be registered with the Commission for Social Care Inspection. The Manager is a Registered Psychiatric Nurse and a Registered General Nurse. South View DS0000069202.V345202.R01.S.doc Version 5.2 Page 22 Quality assurance and quality monitoring practices are in place. Surveys are sent out to residents/relatives on an annual basis to see if they are happy with the home and care that is provided. Regular residents and relatives meetings are held. The home operates an effective system in which they look after the personal allowance of a number of residents. Records were examined to confirm that the fire extinguishers have been serviced within the last year. The Manager said that a rolling programme of servicing of appliances and equipment is in place. Records were available to confirm that water temperatures in resident areas are taken on a monthly basis. A discussion took place with the Deputy Manager in respect of the Health and Safety Guidance to monitor water temperatures weekly. South View DS0000069202.V345202.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 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 South View DS0000069202.V345202.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 OP9 Regulation 13 Requirement The Registered Person must ensure that each individual residents medication is administered one at a time to avoid errors. Pre-potting of medication is not acceptable The Registered Person must replace the floor covering in the toilet on the ground floor of the nursing unit to ensure floors can be cleaned and to prevent the spread of infection. The Registered Person must carry out an assessment of residents to determine if there are sufficient staff on duty to meet the needs of the residents residing at the home The newly appointed Manager must apply to be Registered with the Commission for Social Care Inspection Timescale for action 31/07/07 2 OP21 13 30/09/09 3 OP27 18 31/08/07 4 OP31 8 30/09/07 South View DS0000069202.V345202.R01.S.doc Version 5.2 Page 25 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 OP7 OP16 Good Practice Recommendations Care plan evaluations should be more detailed and include and deteriorations or improvements made. The Complaints policy/procedure should be updated to include information of resident’s rights to complain to commissioning agencies such as Social Services and the Primary Care Trust. The homes statement of purpose and service user guide should also be updated to reflect such information. The Registered Person should give consideration to the Health and Safety Executive Guidelines to monitor bath and shower water temperatures weekly 3 OP38 South View DS0000069202.V345202.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Darlington Area Office No. 1 – Hopetown Studios Brinkburn Road Darlington Co. Durham DL3 6DS 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.V345202.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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