Inspection on 02/08/05 for Staveley Birk Leas Nursing Home

This inspection was carried out on 2nd August 2005.

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 15/03/06

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 8-10 Staveley Road Nab Wood Shipley BD18 4HD Lead Inspector Gillian Sangster Announced 02 08 05 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Staveley Birk Leas Address 8-10 Staveley Road Nab Wood Shipley BD18 4 HD 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) 01274 588288 01274 588288 Mr K Czajka Miss V Bland Care home with nursing 60 Category(ies) of Physical Disability (60) registration, with number of places Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 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 J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out by one inspector between 9am and 4.45pm. The registered manager and senior manager were present during the inspection and the provider joined us for feedback at the end. During the visit time was spent talking to residents, relatives and staff. Many of the bedrooms and communal areas were seen. I looked at records including maintenance and service records, care plans, accident reports, recruitment and staff training records. Detailed information had been provided in the preinspection questionnaire. Comment cards for residents and relatives to complete were sent to the home before the inspection. Eight relative cards were returned and five commented that there were not always enough staff but were satisfied with everything else. One said “Staveley Birk Leas is excellent. Clean, well-furnished and the staff make our son feel he’s part of one big family”. Nine residents returned comment cards and all were satisfied. One said “ the home staff make me feel safe and cared for”. This was the first 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. What the service does well: The home has a relaxed and happy atmosphere. The staff team receive the training and support they need to meet the residents’ needs. All new staff receive induction and foundation training tailored to meet their requirements. The home provides good opportunities for ongoing training and development. Recruitment procedures are thorough making sure that staff are suitable before starting work. Residents gave positive feedback about the care that they received and said that they were treated with respect by staff. Residents said that staff supported them in maintaining their independence and having as much control over their lives as possible. Staff were described as “very good”, “caring” and “excellent”. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 6 Care plans were comprehensive clearly showing what support staff needed to provide to meet the resident’s needs. Residents said that they were consulted about how they wanted their care delivered and this was reflected in the care records. Residents receive input and support from other health and social care specialists who visit the home and staff are prompt in making these arrangements. Residents said there is a good choice of food and said they enjoyed their meals. Maintenance and service agreements are in place and up-to-date to make sure that equipment and services are safe. There is a good accident reporting system. There are good infection control procedures in practice. 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 J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 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 standard(s) 1, 2 and 4. Good written information about the home is available to help residents make an informed choice about moving in. The home has a thorough assessment and admission process including trial visits which is tailored to meet individual needs. This makes sure that the home is able to meet the resident’s need before they move in. EVIDENCE: The home’s brochure has been updated to reflect the changes in the service and copies are due back from the printer in the next few days. The statement of purpose, which gives more detailed information about the service and facilities, is being finalised and copies should be available shortly. The manager said that all residents are assessed before moving into the home. This process involves consultation with the resident, their families and any health or social care professionals who may be involved in their care. Preadmission assessments seen were comprehensive. Residents are encouraged to visit the home for a trial period, which can be a visit of a few hours or extended to a number of days, according to resident’s needs and wishes. Most of the residents I spoke with said that they had visited the home and been given the information they needed before deciding whether to move in. Other residents said that they had been happy for their families to look round on their behalf. One resident had stayed at the home for a four day trial Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 9 period so that the resident, her family and staff could be sure that the home could provide the complex package of care required to meet her needs. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 6, 7 and 9. 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: Five residents’ care records were looked at, including two residents who were in for respite care. It was clear that care plans had been drawn up in consultation with the resident and their family. Information provided by the pre-admission assessment was also included in the care plan. Residents confirmed that staff discussed their care needs with them. One resident said “staff treat me well – they listen to what I want and give me the care I need in the way I want it done”. Some residents are not able to vocalise their needs and preferences, but families I spoke to during the visit said that they were consulted about their relative’s care. Staff I spoke to showed a good understanding of the residents’ needs and discussed how they strived to give each person as good a quality of life as possible. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 11 Residents are supported in making decisions about all aspects of their lives and this includes managing risks. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 15,16 and 17. Residents are supported in maintaining relationships of their choice. Residents rights and choices are respected. Residents enjoy a good choice of nutritious meals. EVIDENCE: Residents are supported and encouraged to maintain relationships with families and friends. Visitors I spoke with said that they can visit when they want and are always made to feel welcome. They said they were offered meals and refreshments and felt included in their relative’s care. Several residents go out regularly to meet with family and friends. Residents said that staff treated them with respect by knocking on doors before entering and making sure their privacy and dignity is maintained when carrying out any personal care tasks. They said they were able to choose how their day was spent and whether they wanted company or not. Residents said relationships with staff were good. Staff were seen to have a good rapport with the residents, chatting with those who were able to hold a conversation and using different methods of communication with those who could not speak to make sure that they were all right. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 13 The home has two separately staffed kitchens and different menus are provided in each side of the home. The manager said that residents can choose to dine in any of six dining rooms or have meals in their own rooms. Menus seen offered a wide variety and choice of foods at each meal. Residents said that they enjoyed the food and described meals as “excellent”, “great” and “very good”. One resident said “they’ll always make me something different if I don’t like it”. I had lunch with the residents in one of the dining rooms. Tables were attractively laid and the meals were well presented. Staff were seen to be attentive but unobtrusive. They sat with residents who needed help with their meals chatting to them and giving them the time they needed. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 18 and 19. 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. EVIDENCE: The care plans gave clear information about how residents liked their care to be delivered. This included information such as preferred times for getting up and going to bed, when they liked to bathe, any preference for gender of staff. Residents said that staff asked them how they liked things done. Relatives of residents who are unable to speak for themselves said that they were consulted about their preferences. 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. Residents praised the support and therapy they received from the physiotherapists. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 15 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 standard(s) These standards were not assessed at this visit. EVIDENCE: Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 24, 25, 26, 27, 28 29 and 30. The home provides an excellent standard of accommodation specifically designed to meet the needs of the client group. EVIDENCE: The home has been fully refurbished and upgraded to provide an excellent standard of accommodation. All bedrooms are single with 40 new rooms providing en suite bathroom facilities. These rooms have ceiling tracking hoists which allow residents to be moved safely from the bedroom into the en suite facilities. All the bedrooms are decorated and furnished to a high standard providing a quality environment. Several of the new rooms have patio doors leading onto gardens or balconies. Residents said that they were very pleased with their rooms and said it was now much easier to get round the home and outside. Bedrooms were very personalised with people’s own personal possessions very much in evidence. As well as the en suite bathrooms there are communal bathrooms and toilets. These are fully equipped to meet the needs of disabled people with a variety of aids and specialist equipment. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 17 There are twelve separate lounge and dining areas throughout the home all of which are decorated and furnished to a high standard. On the rehabilitation unit there is a fully fitted kitchen specifically designed for wheelchair users with equipment that can be height adjusted to meet a variety of needs. Garden areas are well maintained and accessible to the residents. Some of the bedrooms on the first floor have balconies looking out over the gardens. In the rehabilitation unit there is an enclosed courtyard garden with raised flower beds and garden furniture. The home provides a wide range of specialist equipment and facilities to meet the residents’ needs and promote independence. All areas of the home are kept clean and hygienic. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 and 36. Staff receive the training and support they need to maintain their competence and ensure that residents’ needs are met appropriately. Recruitment procedures are robust and protect the residents by making sure that staff are fit and suitable before they start work in the home. Staffing levels are kept under review to ensure that they are sufficient to meet the residents’ needs. EVIDENCE: The home has a training officer who co-ordinates training for staff in the home. All new staff complete induction and foundation training which encompasses all the areas specified in the standards. The induction programme is usually completed over six weeks but the trainer advised that this depends on the individual and more support and time is given if required. The foundation programme is completed over a six month period. All new staff are supernumerary for the first three shifts usually working alongside the trainer. Reviews are carried out after the first three shifts. The new staff then work alongside a senior care assistant for a further ten shifts after which there is a more indepth review of practice. Staff I spoke with said that their induction was good and felt supported. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 19 Eighteen of the care staff have achieved National Vocation Qualification (NVQ) level 2 and other staff are working towards this qualification. Ongoing training and development needs are identified through the supervision and appraisal process. Supervision is provided every two months and appraisals annually. Three staff recruitment files were looked at and all showed that the required checks had been completed. Criminal record bureau checks had been completed but the records did not always show whether it was satisfactory or the date it was received back. The manager advised that employment contracts are issued within eight weeks, however it is recommended that letters of appointment are issued immediately so that staff are aware of the terms and conditions. The recruitment files showed that all new staff are issued with an employee handbook and a Welcome Pack that covers all aspects of their employment. Staffing levels have been increased with the rise in occupancy and remain under review to ensure that residents’ needs are met appropriately. One resident said that he often had to wait for help and thought there should be more staff. Discussions with staff showed that they are still adjusting to the new layout of the building and reorganisation of the home. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Systems are in place to safeguard and promote the health and safety of residents. EVIDENCE: Maintenance and service records were looked at and found to be up-to-date. The fire alarm system and emergency lighting is tested weekly. There are risk assessments recorded in the event of a fire showing which residents would require staff assistance. All staff receive mandatory training including fire safety, moving and handling, health and safety and infection control. Four of the staff are qualified in first aid. Accident reports are well completed and kept separately in each resident’s own file. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 21 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 3 x 3 x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 4 4 4 4 4 4 Standard No 11 12 13 14 15 16 17 x x x x 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 x 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Staveley Birk Leas Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 22 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. 1. Standard op1 Regulation 4 Requirement A copy of the statement of purpose and service user guide must be provided to the Commission. Timescale for action 30/09/05 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 op41 Good Practice Recommendations Policies, procedures and records that have previously been kept for the two separate homes should be amalgamated. Staveley Birk Leas J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley 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 J52 S19854 Staveley Oaks V186793 210605 Stage 4.doc Version 1.30 Page 24 - 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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