Inspection on 15/03/06 for Staveley Birk Leas Nursing Home

This inspection was carried out on 15th March 2006.

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

Staveley Birk Leas Nursing Home 15/05/07

Staveley Birk Leas Nursing Home 02/08/05

Staveley Birk Leas Nursing Home 17/08/04

Similar services:

Snydale Care Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

Beanlands Nursing Home

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

CARE HOME ADULTS 18-65 Staveley Birk Leas Nursing Home 8-10 Staveley Road Nab Wood Shipley West Yorkshire BD18 4HD Lead Inspector Chris Levi Unannounced Inspection 15th March 2006 09:15 Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 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 Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 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 Adults 18-65. 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. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Staveley Birk Leas Nursing Home Address 8-10 Staveley Road Nab Wood Shipley West Yorkshire BD18 4HD 01274 588288 01274 588288 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) Mr Konrad Joseph Czajka Miss Valerie Iris Bland Care Home 60 Category(ies) of Physical disability (60), Terminally ill (1) registration, with number of places Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 Brief Description of the Service: Staveley Birk Leas is a converted, extended property situated in Nab Wood, close to the village of Saltaire. The home is registered to provide nursing care for up to 60 adults with physical disabilities, aged between 18 and 65 years. The home provides long term care but also has a separate rehabilitation unit for up to nine people. The home provides 60 single bedrooms, 46 of which have en suite bath or shower facilities. There are twelve separate lounge and dining areas through the home and a sufficient number of communal toilets and bathrooms. There are well maintained gardens surrounding the home and an enclosed courtyard garden outside the rehabilitation unit. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors between 9.15am and 4.30pm carried out this unannounced inspection. The person in charge was Ms V bland the homes registered manager. This was the first time both inspectors had inspected the home. During the visit time was spent talking to residents, relatives and staff. Some of the bedrooms and communal areas were seen. Records looked at included care plans, medication, staff and residents meeting minutes, management of residents personal allowance monies, complaints, and quality management systems. The inspector had received no comment cards about the service from or residents and relatives since the last inspection. This was the second inspection of the home since an extension and building works have been completed. This home was previously two separate nursing homes – Staveley Oaks and Birk Leas. A large extension has been built to join the two homes together and the existing buildings have been fully refurbished and upgraded. Staveley Birk Leas has been specifically designed to meet the needs of adults with physical disabilities. The registered manager and senior manager were present during the inspection and for feedback at the end. What the service does well: The home has a relaxed and welcoming atmosphere. Residents gave positive feed back about living at the home. One resident comment was “I don’t know what to suggest to improve this place.” A relative said, “ I thank my lucky stars I found this place.” Managers and staff work hard to ensure residents maximize opportunities to be part of the local community. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 6 The training for staff in comprehensive and relevant to assist them understand and support the complex health and social needs of the residents. Standards of catering are high. One resident said “its like a little 3 star hotel.” There is a robust system in place to manage residents monies held at the home. Residents have 24-hour 7days a week access to this money. The home has effective systems in place to safely manage the administration and storage of residents medication. 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. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,5. Relevant information about the services provided at the home is available. This should assist prospective residents and their representatives decide if they wish to live at StaveleyBirkleas. All residents are issued with contacts that are reviewed on an annual basis. This ensures residents are aware of the weekly charges made for the service. EVIDENCE: The manager has updated the written information in the Statement of purpose and service user guide. It is relevant and comprehensive and should help prospective residents and their representatives to decide if they want to live at StaveleyBirkleas.A copy of this information is routinely given to new residents and copies were seen in individual residents rooms. All residents are issued with written copies of their contract of occupancy. These are reviewed on an annual basis to reflect the accurate weekly charges made by the provider for the service. One contract was seen during a review the documentation. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8. Care planning is thorough and residents and their relatives are involved in the process. Residents are supported in making decision about all aspects of their daily lives including managing risks. EVIDENCE: Four care plans were looked at, including one belonging to a resident with a pressure sore. They were comprehensive and the information gathering and agreements had involved both resident and their representatives. However no evidence of residents’ signatures was seen. The nurses review care plans on a monthly basis and any changes in needs are made to the existing plans. The six monthly review on one plan was overdue. The care plans identified that residents are consulted about the risks involved in certain activities. A number of residents gave examples of independent lifestyles that had an element of risk. The risks had been identified and agreed with staff. Two involved residents who are wheelchair users leaving the building unaccompanied. Both said they valued this level of independence. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14. Residents are supported with opportunities for personal development. Opportunities for involvement in community activities for residents are good. Systems for informing residents of internal activities could be improved. EVIDENCE: There was verbal and written evidence that managers and staff work hard to ensure individual residents maximise the opportunities for involvement in the community. Additional funding for individual residents who benefit from community activities is sought from the funding partner. This results in a high level of one to one opportunities, identified by the resident to take place. The home is to be commended for this work. A record of these outings and activities is recorded in a book. This, and residents information confirmed these activities take place. In discussion with residents who are unable or unwilling to leave the home it was clear they were not aware of what activities were available to them. This, in part, is due to the medical conditions of the residents but the inspectors could find no information about what happened in the home on a daily/weekly Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 11 basis. The manager said this information is offered informally, as written notices were ignored by residents. It was suggested that further work be undertaken to find alternatives that would give these residents opportunities to take part in relevant activities within the home. Positive comments were made from at least four residents regarding the provision of activities by the home. They felt they were asked and involved with the choosing of the activities they were provided and involved with. Although standard 17 was not fully inspected, one service user made a comment that was passed on to the management team to investigate. The resident expressed that the meals provided by the home were not suited to her cultural dietary needs. She would like foods that are more suitable to her tastes. Although the manager said that they had dealt with this issue with the resident it was not identified through the care plan. Assurances were given that they would further consult with the resident and make the appropriate records in the care files. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Residents are given the care and support they needed in accordance with their wishes. A variety of health and social care professionals contribute to meeting the residents’ health care needs. The home has a thorough medication policy and staff spoken to had a good awareness of it. The home should adopt a risk assessment process that enables residents to self medicate whenever possible. EVIDENCE: The care plans gave clear information about how residents liked their care to be delivered. Many of the residents have very complex needs and the care records showed the involvement of a variety of different health and social care professionals. These include the tissue viability nurse, the epilepsy nurse, speech therapist, occupational therapist, neurologist and social workers. The home employs a team of physiotherapists and has its own physiotherapy room. This service is value by residents and relatives. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 13 The medication records examined showed a good standard of medication administration within the home. Staff spoken to showed a good awareness of the medication policy. They were also aware of the new system set up for the disposal of medications. The controlled drug stock and records were inspected and found to be correct. A number of residents spoken to said they would like to self medicate if they were given the opportunity. This was discussed with the provider and it was agreed that a thorough self medication risk assessment would be developed to assist residents to self medicate where possible. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. The complaint procedure is correct and appropriately displayed throughout the home. Residents are confident that the home will properly investigate any complaint. The adult protection policy and procedure adopted by the home helps to ensure residents are well protected. EVIDENCE: The complaints procedure is well displayed within the home and residents spoken to said they had a copy of the service user guide which contained details of how to make a complaint. The home keeps a record of complaints that are made in a loose-leaf folder. The records showed that there have been very few complaints made, the last one recorded in 2003. Discussions were held with the management team regarding the complaints record and a recommendation was made that better use of this quality assurance tool would prove helpful with their commitment to improving practice. The home has a thorough policy and procedure relating to Adult Protection issues. The staff members spoken to showed an awareness of what constitutes abuse and how they would recognise it. Residents were very positive with regards to the staff working at the home. They also were aware of what was meant by abuse and were fully aware of what they should do if they experienced it. Improvements have been made in the training of staff in Adult Protection and further training is planned to bolster staff knowledge in this area. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this visit. EVIDENCE: Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35. Staff receive the training and support they need to maintain their competence and ensure that residents’ needs are met appropriately. EVIDENCE: The home has a good training programme for staff. Following and induction training programme, new staff are offered opportunities to undertake NVQ level 2,3 in care. The organisation has a group-training manager who has responsibility for ensuring mandatory and relevant course are available for all levels of staff. The home has a training co-ordinator who has responsibility for identifying and supporting care staff through training programmes. All training undertaken by staff is recorded in their individual training folders. These were seen during the inspection. In discussion with staff, it was confirmed they are given training on understanding the complex health needs of the residents. This provides them with information to understand the physical illness and subsequent behaviour of the individual residents. Recent training included team leading for senior care staff, nurses have undertaken phlebotomy training. Caring for residents with dementia and adult abuse and protection training are ongoing. Training for staff is identified through one to one supervision or appraisals. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40. The home is effectively managed for the benefit of residents. A quality monitoring system is in place. Policies and procedures are effective to ensure the best interests of residents are safeguarded. EVIDENCE: Ms V Bland is the registered manager of StaveleyBirkleas. She had been in post since 1994. She is a registered nurse, with a management qualification, and is a trained NVQ assessor. She has overall responsibility for the 60 residents who live at the home and 90 staff who work there. She has management support from the area manager of the Czajka group, who has responsibility for undertaking monthly regulation 26 visits to the home to assess the standards of the service. Copies of this report are sent to the inspector who values this information as it helps to inform future inspections. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 18 Documentation relating to an annual quality audit were seen, but the information gathered in January 06 had yet to be analysed and an action plan produced. The manager agreed this would be completed by the end of March 06 and a copy sent to the inspector. There was evidence of written minutes of staff and residents meeting. It was recommended that the frequency of meetings be increased, to ensure effective communication. The home has a range of written polices and procedures. Those looked at included medication and management of resident personal allowance monies held by the home. The procedure for the management of resident’s monies is robust but could be further improved by obtaining two signatures during cash transactions. One of the signatures should be that of the resident where possible. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 x x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 X 16 x 17 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Staveley Birk Leas Nursing Home Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x x x DS0000019854.V273356.R01.S.doc Version 5.0 Page 20 No 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. Standard Regulation Requirement Timescale for action 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 3 4 5 Refer to Standard YA19 YA14 YA22 YA36 YA41 Good Practice Recommendations Residents with low weight should be monitored with a specific dietary care plan. In house activities for residents should be better advertised to ensure all residents know what is available on a daily/weekly basis. Complaints should be recorded in a hard-backed book. Staff Meeting should be held every other month to ensure effective communication. Two signatures should be obtained when dealing with resident’s monies. Where possible one signatory should be the resident. Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Staveley Birk Leas Nursing Home DS0000019854.V273356.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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