Inspection on 18/01/06 for Stennards (Fb)

This inspection was carried out on 18th January 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

Stennards (Fb) 15/02/07

Stennards (Fb) 16/08/05

Stennards (Fb) 22/02/05

Stennards (Fb) 21/09/04

Stennards (Fb) 20/01/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Stennards (Fb) 123 Frankley Beeches Road Northfield Birmingham West Midlands B31 5LN Lead Inspector Brenda O`Neill Unannounced Inspection 18th January 2006 09:55 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 Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 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. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Stennards (Fb) Address 123 Frankley Beeches Road Northfield Birmingham West Midlands B31 5LN 0121 477 5573 0121 605 7799 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 Peter David Lee-Harris Mrs Dawn Lee-Harris Miss Rhonda Ann Macey Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th August 2005 Brief Description of the Service: Stennards Frankley Beeches Road is located along Frankley Beeches Road, a short distance from shops and other local amenities in the Northfield area. The home is registered to provide care and accommodation for eighteen older people. The home provides residents with the opportunity to participate in communal activities and to go out for daytime activities at a church centre. The home is a large detached house with ten single bedrooms eight of which have en suite facilities and four double bedrooms all of which have en-suite facilities. The remaining single rooms have wash hand basins. Off road parking is available at the front of the building. To the rear of the house is a large wellmaintained garden. This has many attractive features such as a fountain and there are several secluded areas where people can sit and talk privately with friends or visitors. The garden is laid out so that it is possible to walk round the back of the building on paving passing through various parts of the garden. There is a large sitting room, a separate dining room and two conservatory areas, one of which joins the lounge area to the rear bedroom corridor and the other leads off the dining room. There are good views of the garden from both conservatories. The home does have an entrance at the front of the building for people with mobility difficulties. There are two chair lifts. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over part of day in January 2006 and was the second of the statutory visits to the home for 2005/2006. To get a full overview of all the standards assessed this report should be read in conjunction with the report written following the inspection on August 16th 2005. During this visit a partial tour of the premises was made, three resident’s files and staff training records were sampled as well as other care and health and safety records. The inspector spoke with the manager, one member of staff, the proprietors, four residents and one visitor. What the service does well: This home consistently offers a good level of service to the residents and the requirements made at inspections are minimal. There was a very stable staff team which was very good for the continuity of care of the residents. Without exception all the residents and the relative spoken with were very positive in their comments about the staff team. Comments included: ‘Couldn’t be better.’ ‘Staff are marvellous.’ ‘Staff are very friendly.’ ‘I’m very satisfied with the care at the home.’ There was a lot of evidence that staff were able to recognise the health care needs of the residents and then would follow these up and ensure they were monitored. The residents spoken with were all happy that their personal and health care needs were being met. There were no rigid rules or routines in the home and activities were available for those residents who wished to take part. There was regular ongoing training for staff in a variety of topics to ensure they were equipped with all the necessary skills and knowledge to fulfil their roles. The home was well managed and there were good relationships evident between the manager, residents and staff. The proprietors continued to visit the home virtually every day to offer their support and also knew the residents well. The home offered the residents a good standard of accommodation that was homely and well maintained. Health and safety at the home were very well managed. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 6 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. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 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 Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 Prospective residents were able to visit the home prior to admission to assess the quality, facilities and suitability of the home. The assessment procedures in the home were good and ensured staff knew the needs of the residents prior to admission. EVIDENCE: One of the files sampled was for a resident recently admitted to the home. The file included evidence that a social worker had undertaken an assessment of the individual’s needs and drawn up the initial care plan. A copy of the care plan was available however the manager had experienced difficulties obtaining a copy of the full assessment undertaken by the social worker. The manager had undertaken her own assessment of the individual’s needs on the preview visit to the home and this did cover all the required areas. Had the manager delayed admission to the home waiting for the social work assessment it would have prolonged the individual’s stay in hospital. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The systems in place for care planning were good but the manager needed to ensure that all care plans included all the individual needs of all residents and how these were to be met by staff. Risk assessments needed to be further developed to ensure any risks were identified and minimised. The health care needs of the residents were being met and the system for medication management had improved ensuring the resident’s medication needs were met safely. EVIDENCE: Three resident’s files were sampled. One was for a new admission to the home and the other two for people who had been resident in the home for some time. The manager had drawn up an initial care plan for the new admission which gave some very good detail of her needs particularly in relation to her diet, mental awareness and mobility. The care plan also stressed that it was not known how much assistance the individual would require and therefore staff were to continue to assess and report accordingly. The other two files included ‘ a day in the life’ and gave an overview of what the individuals’ needs were throughout the day and night and how staff were to meet them. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 10 These were generally well detailed and included such things as likes, dislikes and preferences, what the residents were able to do for themselves and also where they were able to make choices. One of the overviews needed some more detail as it included statements such as, continence problems but this was not clarified, help with showering and shaving but it was not clear what help. All files sampled included manual handling risk assessments that detailed how the individual was to be assisted following a fall if uninjured. One file included two manual handling risk assessments as there had been an incident and the assessment was reviewed however it was not clear which manual handling risk assessment was to be followed. It was strongly recommended that only current documentation was kept on the working file to avoid any confusion. There was no evidence of any personal risk assessments on any of the files sampled. The daily records of one of the residents evidenced there was some challenging behaviour this needed to be risk assessed and strategies for managing the behaviour needed to be documented to ensure staff were consistent in their approach. The was good documentation of the residents’ health care needs being identified, followed up and monitored. The district nurse was visiting on the day of the inspection and there were also records of visits from doctors, chiropodists, opticians and dentists. Residents were being weighed on a regular basis. Medication continued to be administered via a 28 day monitored dosage system. Only the manager and staff who had undertaken accredited training were administering medication. Some issues were raised at the last inspection in relation to medication and these had all been addressed: there were no gaps on the medication sheets, all medication was being acknowledged as being received into the home, there was a clear audit trail for all medication and all those checked were correct and the manager was undertaking regular staff drug audits to ensure their competence and that medication was administered appropriately. The privacy and dignity of the residents was well maintained. Residents were able to spend time in their rooms if they wished without being disturbed. All bedroom doors could be locked and lockable facilities were available if required. There was adequate screening available for the double bedrooms and since the last inspection curtaining had been fitted to the glass panels in the bedroom doors to further enhance privacy. Medical consultations took place in the privacy of the resident’s rooms and there were quiet areas where visitors could be received. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 There were no rigid rules or routines in the home and there were activities available if the residents wished to take part. There were no restrictions on visitors to the home within reasonable hours. EVIDENCE: There did not appear to be any rigid rules or routine in the home. It was evident throughout the course of the inspection that staff had very good relationships with the residents. Residents were observed to spend time quietly in their rooms, chatting in small groups, wandering around, reading and taking part in a music and movement session. Although activities were not fully explored documented activities included bingo, Christmas festivities, card games and sing-a-longs. There were no restrictions on visitors to the home during reasonable hours and visitors were seen to come and go throughout the day. The inspector spoke with one of the visitors who stated she was very happy with the care her relative received, that she was always made welcome and that staff were very friendly. Several of the residents went out to a day centre once a week and there were no restrictions on residents going out with friends and relatives or independently if they were able. One of the residents told the inspector she had been out to the local shopping centre with one of the other residents and their relative on the day of the inspection. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 12 A requirement was made following the last inspection in relation to further developing the records of foods served to the residents. This had been met and there was evidence of the various choices made by the residents. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 There was an appropriate complaints procedure at the home that was issued to all residents. The policies and procedures on site and the training staff had received ensured staff were aware of the importance of protecting residents from abuse. EVIDENCE: There was an appropriate complaints procedure on display in the home and a copy of this was issued to all the residents in the welcome pack. No complaints had been lodged with the home and none had been received by the CSCI. The residents at the home had no difficulties approaching the staff with any concerns and appeared confident that they would be addressed. Staff had received training in the protection of vulnerable adults and this was regularly updated. There were policies and procedures on site in relation to adult protection, whistle blowing managing aggression and physical intervention. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25, 26 The home offers residents a safe, well maintained, comfortable and homely place to live. EVIDENCE: There had been no changes to the layout of the home and it was comfortable, safe and well maintained. The proprietors of the home were very frequent visitors and were very quick to address any issues raised. The requirements made following the last inspection, which were relatively minor, had been addressed, for example, new flooring in the laundry, rusting feet on the toilet frames had been addressed and some bedrooms had had new carpets. There were a variety of communal areas in the home which include a smoking area for the residents. All the areas were nicely decorated and all furniture and fittings were domestic in character and varied throughout. The garden area was very pleasant, well maintained and was accessible to the residents with furniture available for their use. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 15 There were adequate toilets and bathrooms throughout the home. Several of the bedrooms had en-suite facilities of toilet and wash hand basin. There were three bathrooms and one fully assisted shower room in the home. One of the bathrooms had a motorised bath seat for ease of access for the residents. In two of the bathrooms the call facility had been extended so that it was accessible from the bath so that residents who wished to be on their own whilst in the bath could summon assistance if necessary. The aids and adaptations throughout the home appeared to meet the needs of the residents and included a floor level shower, hand and grab rails, emergency call system and stair lifts. The emergency call system was the type that allowed calls to be cancelled without staff attending the room where the call had been made however as this had been raised as an issue at the other homes owned by the proprietors the work to rectify this was scheduled to take place at the end of January. Bedrooms sampled varied in size, were comfortable and adequately furnished and decorated. All were appropriately personalised to the occupants choosing and all residents spoken with were very happy with their rooms. The home was warm, well lit and appropriately ventilated. All radiators had been covered and thermostatic mixer valves had been fitted to the hot water outlets to ensure residents would not scald themselves. On the day of the inspection the home was clean and odour free. The laundry was appropriately located and equipped with washing machines, tumble driers and a sluice facility. It was recommended that when the washing machine is replaced one with a sluice facility is purchased. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 30 The appropriate staffing levels were being maintained by a well trained, longstanding staff team who were able to meet the needs of the residents. EVIDENCE: The home maintained a core group of staff that had been employed at the home for a considerable amount of time which was very good for the continuity of care of the residents. There had been no staff turnover since the last inspection. Staffing levels were being maintained at three care staff throughout the waking day (one of whom was a senior) and two staff throughout the night. The manager’s hours were supernumerary to the care rota. There was no cook employed at the home and this was done by staff on duty however domestic staff were employed. The proprietors also attended the home virtually every day. All the residents and the visitor spoken with were very positive in their comments about the staff team and there were friendly relationships evident. The training records for staff were sampled and it was evident that the staff team were well trained on an ongoing basis. There was a yearly training programme in place and all mandatory training was updated including, adult protection, first aid, food hygiene, manual handling and fire procedures. Staff also received training in other topics such as, risk assessment and death, dying and bereavement. Eight of the fourteen staff employed at the home were qualified to NVQ level 2 and three of these also had NVQ level 3. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The manager ensured the smooth running of the home in a competent manner with regular input from the proprietors. The health and safety of the residents and staff was well managed. EVIDENCE: Since the last inspection the registration process had been completed for the deputy manager of the home and she had become the registered manager. She had worked at the home for many years and had a very good knowledge of the residents in her care and the running of a residential home. The manager had completed her Registered Manager’s Award and was pursuing the additional training needed to complete all the necessary qualifications. The proprietors visited the home virtually every day to offer any necessary support. It was evident throughout the course of the inspection that relationships between the manager, residents and staff were very good. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 18 The home had a quality assurance system in place that had been purchased from an outside agency that they were working their way through. The system involved seeking the views of the residents and any other stakeholders in the home. The manager was handling some of the finances for some of the residents. The records for these were sampled and found to be appropriate. All the balances checked were correct, receipts were available for expenditure, where they were able residents were signing for their own money. The manager stated she regularly checked the balances of any monies held however it was recommended that all the balances were audited regularly in the presence of another member of staff. Health and safety of the staff and residents was very well managed. The manager and the proprietors were very proactive in ensuring that the home was a safe place for the residents to live and staff to work. Staff received regular training in safe working practices. There was evidence on site of all the required checks being made on the fire system, fire drills and fire training were up to date. All the equipment on site was regularly serviced and the premises was well maintained. Accident and incident recording and reporting were seen to be appropriate. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 19 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 15(1) Requirement All residents must have a care plan that details how all their needs in relation to health and welfare will be met. All residents must have personal risk assessments. Timescale for action 28/02/06 2. OP7 13(4)(c) 28/02/06 Where any challenging behaviour has been identified there must be written strategies in place for managing it. All resident must have tissue viability and nutritional 28/02/06 screenings. The registered manager must be 30/06/06 qualified to NVQ level 4 in care and management or the equivalent. 3. 4. OP8 OP31 12(4)(a) 9(2)(b)(i) Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 21 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. Refer to Standard OP7 OP26 OP35 Good Practice Recommendations It is strongly recommended that only current information is kept on the working files of the residents. It is recommended that when the washing machine is replaced one with a sluice cycle is purchased. It is recommended that the balances of the resident’s finances are audited by two staff on a regular basis. Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stennards (Fb) DS0000016785.V277797.R01.S.doc Version 5.1 Page 23 - 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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