CARE HOMES FOR OLDER PEOPLE
Stennards (Mos) 133 Anderton Park Road Moseley Birmingham West Midlands B13 9DQ Lead Inspector
Brenda O`Neill Unannounced Inspection 8th December 2005 10:15 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 (Mos) DS0000016787.V269100.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 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 (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Stennards (Mos) Address 133 Anderton Park Road Moseley Birmingham West Midlands B13 9DQ 0121 449 4544 0121 449 4544 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 Ms Catherine Coughlan Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th June 2005 Brief Description of the Service: Stennards Leisure Moseley is a large detached building situated in a residential area of Moseley. It is close to the centre of Moseley with easy access to public transport. The home currently offers residential care to 16 older adults and day care to one older adult. The home aims to provide residents with the opportunity to participate in communal activities such as music, progressive mobility and bingo in the home or to go out for daytime activities at a church centre once a week with transport being provided by Ring and Ride. The accommodation comprises of ten single and three double bedrooms, eight of which have en-suite facilities. The remaining rooms have a wash hand basin. In addition the home has three bathrooms and one shower facility. There are toilets located near to the communal areas. There is also a lounge, dining room and a conservatory which are comfortably furnished and nicely decorated. The kitchen is located off the dining room and has a small room attached for washing up and food preparation. The laundry, sluice and some storage areas are located off this room. There is a well maintained, secluded garden to the rear of the home that is accessible from the conservatory. Off road parking is available at the front of the home. Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over one morning in December 2005. This was the second of the two statutory visits for this home for 2005/2006. To get a full overview of all the standards assessed during this inspection year this report should be read in conjunction with the report written following the inspection on June 9th 2005. During this inspection a partial tour of the premises was made, two resident files were inspected as well as other care and health and safety records. The inspector spoke with the manager, briefly to two members of staff and three residents. What the service does well: What has improved since the last inspection?
Only five requirements were made following the previous inspection, all relatively minor, and all had been met. New carpet had been fitted in the lounge, the worn armchairs had been addressed, the call bell in the shower room had been made accessible form the
Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 6 shower, fridge and freezer temperatures were being recorded on an individual basis and the staff rotas indicated who was undertaking the cooking on each day. All these issues, although minor, served to improve the comfort and safety of the residents. 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 (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 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 (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed at this inspection however standards 2, 3, 4 and 5 were assessed at the previous inspection and found to be met. Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 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 The systems in place for care planning and assessing risks were comprehensive but the manager needed to ensure they were applied consistently. The health care needs of the residents were being met. The medication system needed to be regularly audited to ensure the residents were receiving all their medication. EVIDENCE: The files for the two most recently admitted residents were sampled. Both files included booklets entitled ‘Assessment for good care planning.’ These contained information about the individual and assessments for mental and physical health, falls, pressure care, manual handling and personal risks, personal preferences and needs which included health and hygiene and social and cultural needs. One file also included a lifting assessment which detailed the actions staff were to take if the resident fell and was uninjured, however the other did not. For one of the residents a daily profile had been drawn up from the information included in the booklets which detailed the individual’s daily routine and how and when staff were to offer assistance. This included likes, dislikes and preferences, for example, ‘gets up around 9am’, ‘before going to breakfast tidies her room and makes her bed’, ‘washes herself, looks after her own dentures’ and so on.
Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 10 There was also a personal profile which gave staff information on the individual’s past, preferred leisure activities, mobility and communication. The other file sampled was for a resident who had attended the home for day care prior to admission as a resident and the daily routine for this person had not been changed to reflect the change. There was no information in relation to the individual’s needs during the evening, night and early morning. All the required risk assessments, with the exception of the manual handling risk assessment for one resident, were in place. The care plans were being reviewed monthly. There was documented evidence that when health care needs were identified they were followed up and monitored by staff. There was evidence on the residents’ files sampled of visits from the G.P., district nurse, chiropodist, optician and psychiatrist. The manager at the home had a very good relationship with the G.P. and could consult him at any time for guidance or advice. The weights of the residents were being monitored. Tissue viability and nutritional screenings had been undertaken as well as continence assessments. The bulk of the medication continued to be administered via 28 day monitored dosage system. No stocks of medication were being held in the home and there were no homely remedies therefore medication in the home was kept to an absolute minimum. Medication that was being administered from boxes was audited and some discrepancies were found. The tablets remaining in some of the boxes did not correspond with the amounts received and the amounts that had been administered. The manager needed to undertake regular staff audits to ensure the medication was administered and recorded correctly to address the issues raised. Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 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 There were no rigid rules or routines in the home. There were a variety of activities on offer to try and ensure the residents social needs were met. EVIDENCE: When the inspector arrived at the home some of the residents had just finished breakfast, others were sitting the lounge and entrance hall and some were getting ready to go out for a Christmas meal. The range of activities offered in the home was not fully explored at this inspection however activity records evidenced that a range of activities were on offer to those residents who wished to take part. Several of the residents continued to attend a day centre once a week at a Baptist church. Whilst at the day centre they met up with residents from the other homes owned by the same proprietors. Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These standards were not assessed at this inspection however standards 16 and 18 were assessed at the previous inspection and found to be met. Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 13 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, 22, 24, 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. It was comfortable safe and well maintained. The communal areas were comfortable with a variety of furnishings which helped give them a very homely feel. The carpet in the lounge had been replaced since the last inspection and the worn armchairs had been addressed. The dining room in the home was quite small but there was also a dining table in the conservatory if required. There were adequate toilets and bathrooms throughout the home. Several of the bedrooms had en-suite facilities of wash hand basin and toilet. There were three bathrooms throughout the home one of which had a bath hoist seat for those residents that needed assistance. There was also a shower room that had floor level access and allowed for full assistance from staff.
Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 14 The call point in this room had been made accessible from the shower since the last inspection as was required. There were some aids and adaptations throughout the home including, grab and hand rails, emergency call system and stair lift which appeared to meet the needs of the present resident group. The manager raised the issue that calls made on the emergency call system could be cancelled on a panel in the entrance hall. This was the same system as in the other homes owned by the same proprietors and had been raised with them. This was not good practice as staff could cancel a call and not attend the location. The inspector was informed this was to be addressed in the New Year. It was noted that several wheelchairs in use did not have the footrests attached. This issue was discussed with the manager, as it could be hazardous for the residents. The manager was advised that where footrests were not to be used a risk assessment must be undertaken and documented on the individual residents’ files. Bedrooms varied in size and were generally bright, airy and comfortable. All were personalised to the occupants choosing. The areas of the home toured on the day of the inspection were clean and hygienic. The kitchen and laundry were not inspected during this visit. There had been a recent visit made by the environmental health officer and the inspector was informed that all the requirements made had been met. Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 15 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, 29 Appropriate staffing levels were being maintained by a long standing staff team that was very good for the continuity of care of the residents. To ensure the safety of the residents the manager needed to undertake all the appropriate checks on staff members prior to their commencing their employment. EVIDENCE: Appropriate staffing levels were being maintained to meet the needs of the residents. Staff undertook a multi role of caring, cooking and cleaning. Since the last inspection the manager was highlighting on the rota who was cooking each day. Staff turnover at the home was very low which was very good for the continuity of care of the residents. There were friendly relationships evident between the staff and the residents. One care assistant had been appointed since the last inspection and her file was being compiled. The inspector was informed that a CRB form had been completed but no POVA first check had been undertaken as the person was well known to the manager and the proprietors and had worked for them previously. The previous employment was a considerable amount of time ago and it could not be guaranteed that the member of staff would be supervised at all times therefore all the necessary checks still needed to be undertaken prior to employment. Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 16 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, 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: The manager of the home had been in post for several years. She had a very good knowledge of the residents in her care and the running of a residential home. The manager received regular support from the proprietors who visited the home virtually every day. Throughout the course of the inspection it was evident there were good relationships between the manager, residents and staff and the residents were comfortable in her presence. Health and safety in the home was very well maintained. There was evidence on site of the up to date servicing of all equipment. All the in house checks on the fire system were up to date, a fire drill had been carried out and the fire risk assessment had been updated.
Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 17 The inspector was aware that staff had ongoing training in safe working practices and the reporting of accidents and incidents to the CSCI was being carried out appropriately. Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 2 X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 19 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 care plans in place that detail how all their needs in relation to health and welfare are to be met by staff. All residents must have manual handling risk assessments that detail the actions to be taken staff in the event of a fall. Regular staff drug audits before and after a drug round must take place to confirm staff competence in medicine management. Footrests must be used on wheelchairs unless otherwise clearly documented on a risk assessment. The emergency call system should be of a type that the call can only be cancelled from the point where it was made. All staff must have a minimum of a POVA first check before they commence their employment unless they are fully supervised at all times. Timescale for action 14/01/06 2 OP7 13(5) 14/01/06 3 OP9 13(2) 01/01/06 4 OP22 13(4)(c) 14/01/06 5 OP22 23(2)(n) 01/04/06 6 OP29 19 Sch 2 01/01/06 Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Stennards (Mos) DS0000016787.V269100.R01.S.doc Version 5.0 Page 21 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
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