Inspection on 17/05/05 for Stratford Court

This inspection was carried out on 17th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stratford Court 04/07/06

Stratford Court 28/11/05

Stratford Court 27/10/04

Stratford Court 11/05/04

Stratford Court 10/02/04

Stratford Court 12/08/03

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Maple Lodge

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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 Stratford Court 35 Highfield Road Hall Green Birmingham B28 0EU Lead Inspector Jane Walton Unannounced 17 May 2005 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 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. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Stratford Court Address 35 Highfield Road, Hall Green, Birmingham, West Midlands, B28 0EU 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) 0121 778 3366 0121 778 6288 Mr Colin Wilkins and Mrs Carole Wilkins Mrs Carole Wilkins Care Home 30 Category(ies) of OP Old Age (30) registration, with number of places Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate a maximum of 30 people for reasons of old age. (30 OP) Date of last inspection 27 October 2004 Brief Description of the Service: Stratford Court provides residential care for up to 30 older people. It is a purpose built care home conveniently placed for local amenities and public transport. The Home offers accommodation ranging from single rooms with en suite facilities to studio type accommodation. These studio rooms are for single occupancy and also have en suite facilities. They are intended for use by residents who are more independent but who will still benefit from the security of 24-hour supervision, care and support services. There is one double room with en suite for use by couples or friends. The main complex has three separate lounge areas, a large dining room, and a hairdressing salon. Disabled toilet facilities are available close to the lounges and dining room. Accommodation is on 2 floors and an eight-person lift provides access between floors.The Home is equipped with a loop system and talking books for service users with sensory difficulties. Television and telephone points are sited in all bedrooms and a payphone is also available for residents use. Stratford Court also offers both long and short-term respite care. There is a well tended garden with seating for residents to enjoy, and some car parking facilities are available for visitors. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one day and the inspector was assisted throughout by the deputy manager. There were 29 residents living in the home at the time of the inspection and the inspector spoke to 6 of them, to obtain their views about their lives in the home. Informal discussion took place with 4 members of the care staff. Three residents care plans were sampled and an audit of the medication administration in the home was carried out. Copies of four weeks of staff rotas and menus were taken away for analysis after the inspection. What the service does well: What has improved since the last inspection? The registered manager has now completed her Care Managers Award, and has also undertaken a course to qualify as an accredited Moving and Handling trainer. Levels of NVQ2 or equivalent trained care staff have increased significantly since the previous inspection, thus ensuring that the service delivered to the home is of a high quality. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 Page 6 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. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 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 standard(s) 1,3 & 5 Residents are able to make an informed choice about the home. All the practices and procedures surrounding the admission of new residents were adequate and appropriate to ensure needs are met. EVIDENCE: The home has a comprehensive statement of purpose and service users guide that provides all relevant information for the resident and their relatives. The manager of the home undertakes a pre admission assessment of all potential residents, and will visit them at home or in hospital as necessary, to ensure that the home is able to meet their identified needs. However, the assessment for one resident whose care plan was examined could not be evidenced. Prospective residents are invited to move into the home for a trial period of 4 weeks that can be extended if needed. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 & 10 The health and care needs of residents are well met and include multi disciplinary working. The systems for the administration of medication were varied leading to a potentially poor outcome for some service users. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Care plans were comprehensive, identified needs through the use of a range of risk assessments, and detailed the care management in an easy to understand manner. Staff spoken to were able to demonstrate familiarity with individual residents care needs and their management. Care plans are reviewed regularly, and have been written with the involvement of the resident. Daily records generally, did not contain sufficient detail to reflect the day to day life of the residents. Visits to the home by GP’s, District Nurses, Chiropodist, Dentist and the Optician are recorded appropriately. Medication storage is appropriate and the audits of the Monitored Dosage System (MDS) counts were accurate, and corresponded to the MAR charts. Two handwritten items on one MAR chart had not had the quantity received recorded, so it was not possible to audit for these boxed medicines. Some, but not all Medicine Administration Record (MAR) charts had a corresponding copy of the prescription to enable accuracy checks to be carried out. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 Page 10 Sharps disposal boxes in use were seen in the general office and not in the locked medication cupboard. This issue was addressed with the deputy manager who rectified the situation immediately. Care staff were observed to address residents with respect, and one resident said “ All the staff are kind and polite to me”. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 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 standard(s) 12, 13, & 15 Residents have a range of activities available that meet their expectations and preferences. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and choices, and promotes their well-being. The arrangements for residents to access the community and their relations were in place ensuring the promotion of independence. EVIDENCE: Residents are offered a range of activities to participate in if they so wish. These include both indoor activities and crafts and trips out to places of interest, such as the Black Country Museum. Visitors are welcomed to the home. One resident said “ My friends come to take me out” and another said “I go out to church on a Sunday”. The preferences of the residents are documented, and those spoken to stated that these were respected by the care staff wherever possible. One resident said, “ I always get up quite early, but other people get up much later than I do”. The meals provided by the home are of a high standard, and menus demonstrate a well-balanced and nutritious diet is offered, with plenty of choice. Fresh fruit and vegetables were in evidence. Special diets are catered for where needed. Breakfast is served in residents’ bedrooms, and all other meals, in the large comfortable dining room. Dining tables are attractively and appropriately laid. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 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 standard(s) 16 &18 The home has a satisfactory complaints procedure that is accessible to residents and visitors so that they are aware of how to make a complaint ensuring the promotion of protection matters. EVIDENCE: The home had not recorded any complaints since the previous inspection. The complaints policy and procedure includes all the information required to enable a person to make a complaint if they should wish to do so. One resident said “ I have lived here for a while and have never had cause to complain about anything, everyone is very good to me” The adult protection policy and procedure incorporated the Birmingham Multi Agency Guidelines. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 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 standard(s) 19, 21 & 26 The standard of the environment within this home is very high, providing residents with an attractive and homely place to live. EVIDENCE: The areas of the home seen at the time of the inspection were very clean and there were no unpleasant odours. The decoration, furnishings and fittings in the home were of a high standard and the areas seen were in a good state of repair. Evidence was seen that the home has a rolling programme of decoration and refurbishment, and residents’ bedrooms are decorated between occupancies. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, & 30 The staff work well as a team, and their high morale results in a motivated workforce that works positively with residents to improve their quality of life. The level of staff training ensures that residents are in safe hands and their assessed needs are met. EVIDENCE: Staffing rotas identified that staffing levels are maintained at sufficient levels according to the numbers and dependency of residents in the home. The manager was on holiday at the time of the inspection and the deputy manager was in charge in a supernumerary capacity, supported by the administrator, and adequate numbers of care staff to meet the needs of the current residents. The deputy manager lives on site and is available in an emergency situation. The home has a very high ratio of staff who are trained to NVQ level 2 or equivalent. Staff spoken to confirmed that they had undertaken a range of training, both statutory and in other subjects enabling them to enhance the level of care provided to residents. One resident said,” The staff here look after me very well, as I find it a bit difficult to get around these days”. The staff also confirmed that they work well as a team, and there is a core of long standing staff working in the home, that offers stability and consistency for the residents. It was not possible to examine the staff files, as they were locked in an office to which only the manager and registered provider have access. This meant that the outstanding requirement from the previous inspection relating to POVA checks for staff employed since July 2004, was not possible to confirm. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 Page 15 The deputy manager was informed of the necessity for all records relating to the running of the home must be available for inspection when requested. Individual staff training records could not be accessed, as they are kept in the staff files. The deputy manager stated that due to great difficulties in sourcing suitable training, the manager had completed a course as an accredited trainer of moving and handling techniques, and a programme of training was due to be rolled out to staff upon her return from holiday. The provision of statutory training in moving and handling for all staff is an outstanding requirement from the previous inspection. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 37, & 38 Overall the management of the home was very good ensuring a high quality of service is offered to the residents. EVIDENCE: The registered manager of the home is a qualified nurse who has a wealth of experience in managing a care home. She has completed her Care manager’s award qualification. The deputy manager has an NVQ4 qualification in care and management, and demonstrated her understanding of the needs of the residents currently living in the home. The staff of the home are not responsible for the management of any residents’ financial affairs. There are a range of policies and procedures available in the home that help to safeguard the rights and best interests of the residents. The general standard of all the records examined were of a high standard. Fire records clearly demonstrated that fire alarm test and drills are regularly carried out. Fire fighting equipment is tested as are emergency lights. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 Page 17 The requirements made following a visit by a West Midlands Fire Service officer were seen to have been addressed immediately, and there is an up to date risk assessment in place. Fire training for staff was seen, in some instances, to be overdue. Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 4 COMPLAINTS AND PROTECTION 4 x 4 x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x N/A x 2 3 Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 Page 19 yes 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 OP9 Regulation 13(2) Requirement The registered manager must ensure that a copy of the current prescription is kept with the Medicine Administration Record (MAR) charts for accurate cross referencing purposes. All handwritten items on the MAR must include a record of the quantities received into the home In use sharps disposal boxes must be kept in the locked medication room. All staff recruited since July 2004 must have had a POVA check carried out. (This requirement is outstanding from October 2004) Timescale for action 04 June 2005 2. OP9 13(2) 18 May 2005 18 May 2005 18 May 2005 18 May 2005 31 July 2005 3. 4. OP9 OP29 13(2) 19(4) 5. OP30 6. OP38 All records required for inspection must be available at the time of the inspection. 18(1)(c, i) All staff must receive the statutory training in moving and handling from an accredited trainer. (This requirement is outstanding from October 2004) 23(4)(d) All staff must receive fire training on a six monthly basis. 18 June 2005 Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 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. 1. Refer to Standard Good Practice Recommendations Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 1st Floor Ladywood House 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 Stratford Court E54 S16788 Stratford Court V232093 170505 Stage 4.doc Version 1.30 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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