Inspection on 15/05/07 for Strawberry Bank

This inspection was carried out on 15th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Strawberry Bank 04/02/10

Strawberry Bank 17/09/09

Strawberry Bank 07/08/09

Strawberry Bank 08/07/09

Strawberry Bank 16/01/09

Strawberry Bank 24/01/08

Strawberry Bank 26/09/07

Strawberry Bank 04/07/06

Strawberry Bank 19/10/05

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Strawberry Bank 17 Strawberry Bank Liversedge West Yorkshire WF15 6JT Lead Inspector Helen Battle Unannounced Inspection 15th May 2007 09:00 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 Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 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. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Strawberry Bank Address 17 Strawberry Bank Liversedge West Yorkshire WF15 6JT 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) 01924 410471 01924 405070 info@strawberrybankcarehome.co.uk Prince Edward Anojan Joseph Miss Claire L Allen Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To forward a Statement of Purpose and Service User Guide within three months of becoming the registered provider. To complete Schedule 1 of the Fire Safety Officers report Date of last inspection 9th January 2007 Brief Description of the Service: Strawberry Bank Care Home provides personal care to older people over the age of 65 years. The home is located at the head of a quiet cul-de-sac, off the main Halifax road into Liversedge. The accommodation is over three floors, with a lounge, and a dining area on the middle floor. There is a mixture of both single and shared bedrooms. There is also a patio to the rear of the property, where service users may sit in the warmer months of the year. The Provider informed the Commission for Social Care Inspection on the 01/05/07 that the fees range from £347.02 - £358.80 per week. There are additional charges for hairdressing, newspapers, and magazines. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this full inspection a visit to the home took place. The inspector visited the home unannounced from 09.00hrs to 15.15hrs. Whilst at the home, key documents that give information about how people are looked after and how the home makes sure staff are fit to work at the home were looked at, and so were all the rooms and garden. 5 members of staff were spoken with. Before the visit the manager was requested to provide CSCI with information about the people who live at Strawberry Bank, the staff that work there and any incidents or accidents that have happened there since the last inspection. This was returned to the Commission prior to the visit taking place. This information has helped form the judgements made about how the home is performing. Surveys were sent out to relatives of three people living at the home, and to people’s doctors and social workers. At the time of writing this report, responses had been received from one relative. The comments in the survey were positive about the standard of care provided by the staff at the home. Comments from relatives included: “Staff help new residents settle in.” “Good on one to ones.” “Keep relatives informed”. Comments from people living in the home on the day of the visit included: “The food is good”. “we always get a choice”. “ I have a nice room”. “we have a laugh and a joke with staff”. “you can tell the staff anything and it isn’t repeated, they just sort it out for you”. The inspector would like to thank all the staff and people living at the home for their hospitality and co-operation during this visit. What the service does well: The manager generally assesses people prior to moving into the home to ensure their needs can be met. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 6 Staff carry out risk assessments and develop care plans for staff to follow and provide a consistent plan of care. The home delivers a good standard of personal care. People who live at the home are treated with dignity and respect. Staff support relatives. Medication systems are well managed. 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. The summary of this inspection report can be made available in other formats on request. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 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 Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are properly assessed before moving into the home with the assurance that their needs will be met, however this is not always documented. EVIDENCE: This home does not provide intermediate care. The records of a person recently admitted to the home were examined. These did not contain evidence of a pre-admission assessment that would have identified what care that person needed when they came to live here. The manager, Miss Allen stated that the person and their relative had been to look round the home and that an assessment had taken place then, and the person moved into the home on a trial basis to see if they settled there. The records regarding pre admission assessment were put in place before the end of this Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 9 visit. This is important so the home can be sure that they can meet people’s needs properly when they move into the home. Three other records were examined and all were found to have appropriate community care assessments, which are carried out by Social Services, prior to admission and provided the information the home needed about these people. A response in a survey from a relative indicated that staff are very good at helping new people settle into the home. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The level of care people need, which includes their health, personal and social cares needs are clearly highlighted within their care plan. EVIDENCE: The care plans of four people living at the home were examined. Three of these were clear documents, which included assessments to identify whether individuals are at risk of falling, need help to move about the home, developing pressure sores or having problems eating and drinking. The other care plan however was for a person who recently moved into to the home, and was not fully completed or clear in how this person’s needs were to be met. This was rectified before the end of this visit. Discussion took place with the manager regarding the timing and content of care pans for newly admitted people. The manager agreed to improve this aspect of documentation. The daily records examined were detailed in their content, however where a risk is identified Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 11 regarding a person’s likelihood of developing pressure sores, this should be referred to in the daily records on a daily basis stating the condition of their skin. The people living at the home on the day of this visit, looked well cared for, comfortable and relaxed. People responded well to the staff and it was evident from observing staff interaction with people living in the home that they knew each individual’s likes, dislikes and needs. Feedback from people living in the home spoken to on the day of this visit was positive, who said that staff were kind and pleasant, and they were able to have a laugh and a joke with them. People who live in the home said that staff were approachable. The healthcare needs of people are met, evidence was seen of involvement from people’s doctors, opticians, dentists and other healthcare professionals where needed. The medication of three people was checked and all but one amount were found to tally with the records held. This was due to an administrative error which staff agreed to remedy straightaway. Records were clear and accurate, and medication was stored correctly. Systems are in place to ensure safe administration of medication. During this visit staff were observed to maintain the privacy and dignity of people. Staff approached and spoke to people in an appropriate manner. Feedback from a relatives survey was extremely positive about the staff and the care delivered; saying that the staff do a good job. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lifestyle at the home satisfies the needs of the people living there, and encourages the involvement of family and friends. EVIDENCE: During the visit individual people were seen to be participating in various activities including watching television, looking at newspapers and receiving visitors. Visitors were seen to come and go to the home throughout the day. The hairdresser visits the home every week. Records examined indicated that people living at the home have various activities organised such as a weekly visit from an aromatherapist, motivation class, karaoke, arts and crafts, dominoes, card games, personal library service. Staff spoken to said that other activities included playing dominoes and a small number of people are taken out by families on a regular basis. Staff also take people out for short walks. This was seen to happen on the day of this visit. The manager’s dog is a much loved pet, which the people at the home evidently enjoy seeing. During this visit, one person was asked where they would like to go on a shopping trip by a member of staff, and this was Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 13 organised to go to a local town by taxi. People spoken to during this visit stated that they have choices in where and how they spend their day and what they have to eat. Choices are promoted as to what time people get up and go to bed and what they eat. There is a menu in place at the home which demonstrated that a nutritionally balanced and varied diet is offered. The lunchtime meal on the day of the visit was chicken, mashed potato, roast potatoes, carrots and broccoli followed by Coconut and jam sponge and custard. The food served was sampled by the inspector and was warm and tasty. People living at the home appeared to enjoy the meal and were assisted in an appropriate manner. Where possible people are encouraged to maintain as much independence as they can. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People can be confident that their complaint will be dealt with effectively, however due to poor recruitment systems people are not adequately protected from abuse. EVIDENCE: All staff have previously received training in adult protection issues, and the training is planned to be refreshed this summer. The adult protection policy and procedure in place at the home gives adequate information for staff to refer to. Staff spoken to appeared to have an adequate understanding of adult protection issues. Recruitment practice at the home is poor, with references and checks not being fully obtained prior to staff commencing work. The complaints procedure is displayed at the home and in the policies and procedure file. One complaint received by the home is in the process of being resolved. This complaint was not regarding the care of the people living at the home and clear records were seen regarding the process of the action taken. People spoken to said that they would feel comfortable in approaching the manager if they had any concerns. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The home is generally safe and maintained and the standard of decoration and furniture in the home is adequate, however, the home is clean but there are some unpleasant odours in some of the bedrooms. EVIDENCE: As part of this visit a tour of the building was carried out. Since the last visit, building work has commenced and is ongoing to improve the environment. Work to install a lift shaft is nearly completed. This will remove the need to use the current stair lifts and will make moving around the home easier and safer for some people. Plans to build a new extension to ensure all rooms are for single occupancy is due to start this summer. One room has been converted into an ensuite room and decoration has taken place in ten bedrooms and the main lounge area. Radiator covers have also been fitted as required under health and safety law. Part of the new extension will include a new kitchen. The manager stated that decoration of the corridors around where the building work is to be carried out will be completed as part of the improvements. The Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 16 weekend before this visit there had been heavy rain and a leak into the home. This is being addressed. Generally the home was clean and odour free, however there were four rooms where there was a noticeable odour of urine. The manager agreed to try address this. Window restrictors were not in place on three bedroom windows and should be fitted to ensure the safety of people using the service. This is also highlighted in the “Management and administration” section of this report. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People’s needs are met by trained and qualified staff who have not undergone a thorough recruitment process before they are allowed to work in the home. EVIDENCE: Training records are in place at the home and records kept in individual staff members files. All staff received fire training in December 2006 and moving and handling training in February 2007. Other training has included medication administration, aggression management, food hygiene and dementia care. Training already planned this year includes adult protection, infection control health and safety, prevention and care of pressure sores, and oral health. Eleven members of staff have achieved the NVQ level 2 award in care, which means that 60 of care staff have achieved this standard. Whilst observing staff during this visit, there were no issues raised in the quality of the care provided. Recruitment processes at the home are poor. The records of four members of staff were checked and none had all the required information and checks in place. Gaps in information regarding references POVA checks and CRB checks were missing. Some references obtained were not adequate as they were from family or friends rather than a previous employer. Application forms were not always fully completed. This is not acceptable practice and must be addressed. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 18 The manager must carry out a full audit of these records and ensure that satisfactory references and checks are made for each member of staff. New employees must not commence work at the home until these checks are made, so that everything possible has been done to ensure that people are cared for by appropriate people. Staff do receive induction training when they start work at the home and records are in place for the six month induction process. Discussion took place with the manager regarding the need to record initial training given to ensure staff are safe to work in the home, such as fire safety, moving and handling and health and safety. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The home is adequately managed, people are generally kept safe by health and safety practices; they are involved in making improvements as part of the home’s quality assurance system. EVIDENCE: Miss Allen is the registered manager of the service and is currently working towards achieving the Registered Managers Award. Monthly management visit reports by the provider are documented and were available for inspection. The environmental health officer visited the home in December 2006 and made some recommendations to improve the systems at the home. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 20 Weekly checks of the fire system and emergency lighting system are recorded as being carried out. Any issues which need rectifying are recorded. Hot water temperatures were also seen to be recorded on a weekly basis, however one room was found not to have hot water, and another room did not have sufficient hot water pressure. The records of two people’s personal monies were examined. Both tallied with the records held. Window restrictors were not in place on three bedroom windows and should be fitted to ensure the safety of people using the service. This issue is also highlighted in the environment section of this report. Quality assurance surveys are sent out by the home annually and these results published and posted on the notice board. Copies are available should anyone wish to look at them. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 21 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 22 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. 2. Standard OP18 OP29 Regulation 13 (6) 19 Requirement Timescale for action 15/07/07 3. 4. OP38 OP38 13 (4) 23 (2) (j) Recruitment practice must be thorough in order to protect people who use the service. The required checks and 15/07/07 documents as stated in Schedule 2 of the Care Homes Regulations 2001 must be obtained prior to staff working in the home. Window restrictors must be fitted 31/05/07 to ensure the safety of people living at the home. There must be a hot water 31/05/07 supply to all sinks in people’s rooms. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. Refer to Standard OP3 OP7 OP19 OP19 OP22 OP26 OP26 OP30 OP31 Good Practice Recommendations All pre admission assessments should be fully documented. Every person living at the home should have a plan of care in place from the day they move in. The lounge chairs should be cleaned/ replaced. The corridor carpets should be cleaned/ replaced with a more serviceable carpet. The building work and programme of refurbishment should be continued. The home should provide handrails in corridors. The laundry floor finishes should be impermeable and wall finishes cleanable. The odour in the four bedrooms identified, should be eliminated. A record of initial induction should be recorded. The manager should have an NVQ level 4 in management and care or equivalent. The manager confirmed that she has almost completed the qualification. Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Strawberry Bank DS0000063274.V339926.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!