Inspection on 17/09/09 for Strawberry Bank

This inspection was carried out on 17th September 2009.

CQC found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Strawberry Bank 04/02/10

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 15/05/07

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 17/02/2010.

Random inspection report Care homes for older people Name: Address: Strawberry Bank 17 Strawberry Bank Liversedge West Yorkshire WF15 6JT zero star poor service 09/02/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Lynda Jones Date: 1 7 0 9 2 0 0 9 Information about the care home Name of care home: Address: Strawberry Bank 17 Strawberry Bank Liversedge West Yorkshire WF15 6JT 01924410471 01924405070 info@strawberrybankcarehome.co.uk www.strawberrybankcarehome.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Prince Edward Anojan Joseph care home 24 Number of places (if applicable): Under 65 Over 65 24 old age, not falling within any other category Conditions of registration: 0 To complete Schedule 1 of the Fire Safety Officers report To forward a Statement of Purpose and Service User Guide within three months of becoming the registered provider. Date of last inspection Brief description of the care home Strawberry Bank provides personal care and support for 24 older people. The home is located at the head of a quiet cul-de-sac, off the main Halifax road into Liversedge. Accommodation is on three floors, with a lounge, and a dining area on the middle floor. A passenger lift serves all floors. There is a mixture of both single and shared bedrooms. There is also a patio to the rear of the property, where people can sit out in the warmer months of the year. In addition to the weekly fee there are additional charges for hairdressing, newspapers, and magazines. Information about the home and the services provided is available from the home in the statement of purpose and Care Homes for Older People Page 2 of 15 0 8 0 7 2 0 0 9 Brief description of the care home service user guide Care Homes for Older People Page 3 of 15 What we found: We have been concerned about the service provided at Strawberry Bank since we carried out a key inspection in February 2009. We carried out additional random inspections in March and July 2009 because we were concerned that the home had insufficient funds to purchase food and cleaning materials and there were insufficient staff on duty to meet the needs of the people living there. The registered provider of the service is Mr P.E.A. Joseph. Strawberry Bank went into administration on 30 June 2009. P&A Partnership have been appointed as joint administrators to PJ Care Homes Ltd. PJ Care Homes Ltd appears to be involved in the running of Strawberry Bank Care Homes but is not registered with us as the provider of this service. The joint administrators have appointed WM Healthcare to advise on the running of the service. The last key inspection took place on 7 August 2009. The rating for the service is zero star - poor service. In the report from that inspection we raised a number of concerns about the poor quality of the service provided. We said peoples health care and personal support needs are not being met; people are not being properly protected because the staff have not received appropriate training; people are living in a poorly maintained home; people are being placed at risk because of poor recruitment practices. We said the home is not being managed properly and is not being run in the best intersts of the people living there. We made a number of requirements in our last report which set out what action must be taken to meet the Care Homes Regulations 2001 and the National Minimum Standards. We also set timescales for this action to be taken. This inspection was carried out by two inspectors over 5:45 hours. On the day of inspection there were 14 people living at the home. The purpose of this random inspection was to examine what action has been taken to meet the requirements in the last key inspection report . We continue to have serious concerns about the day to day management of the home and the lack of clarity of lines of management. The registered manager is off sick and has been unavailable since August 2009. WM Healthcare have been appointed to offer management advice to the administrators and to the staff but it is not clear who has day to day management responsibility. When we arrived at the home there were two members of care staff and two ancillary staff on duty. One member of staff was administering morning medication. When we asked who was in charge this member of staff said she was a carer but acted up as senior sometimes. A further member of staff arrived at the home a short time later and told us she was a senior carer. Neither members of care staff had access to telephone numbers to contact anyone from the management company to inform them of our visit or had any Care Homes for Older People Page 4 of 15 keys to access the main office where records were stored. During the inspection contact was made with the management company and keys were located which enabled access to records. The circumstances on the day of the visit further compound our concerns about responsibility for the management of the home. In previous reports we have said that care plans and risk assessments must be kept up to date and reviewed regularly. This is to make sure that people receive the care and support that they require. We found little improvement in the care plans on this inspection. We looked at two care plans and we could see that a new planning system was in the process of being introduced. A member of staff on duty told us it would take at least another two weeks before the new system was operational. The plans we looked at were incomplete, they did not contain sufficient information about the action staff must take to make sure that peoples needs are being met. For example, one of the plans contained several new assessment tools, some had been completed, others were blank. A note at the front of one plan gave details of the information that was still required - needs dentist, needs hearing test update, falls risk assessor to visit, personal history, staff signature sheet, food preferences, needs funeral details filling in. It was not clear who was responsible for gathering this information and we could find no information about timescales for completing the plan. The personal care needs identified for this person had been noted on 8/8/09 and were due to be reviewed on 8/9/09 but this had not been done. It was not clear who was responsible for reviewing the plan. The staff are not always aware of up to date information about peoples daily care needs and there is no one in day to day control to ensure that all staff are following the same plan. This means that people may not be receiving the care that they need. For example, a nutritional assessment and nutritional screening tool had been completed showing that one person was at risk of malnourishment. The score on the assessment indicated that a food chart needed to be completed, nutritional supplements needed to be considered and the situation discussed with the dietician. The dietician had been contacted and had left written advice for staff suggesting they provide milky coffee drinks with biscuits and trial an earlier evening meal for this individual. The advice from the dietician had not been added to the care plan, it had been written up in the seniors communication book. We asked staff on duty about the dieticians advice ( the advice was given four weeks before our visit), one staff member was unaware of the dieticians visit but was under the impression that this individual should not have a milky drink other than at bedtime. Another member of staff said she was not sure if the dietician had visited, but she thought that milky drinks could be given. We looked at the record of meals and drinks kept in respect of this individual beween 12/9/09 and 17/9/09. We could see evidence of drinks of coffee being given but there was no reference to whether the coffee was made with milk (some of the records relating to other people specifically stated whether drinks were made with milk). The records of drinks are not accurate representations of fluid intake, for example, some staff simply record cup of coffee, others record more detailed measurements eg. 100ml; 200ml. The records of food intake also lack detail; on the day we visited, the records indicate Care Homes for Older People Page 5 of 15 that this individual had liver, mash and veg for lunch. This was the meal on the menu for the day and the dish presented to this person but very little of the meal was actually eaten. This means that this person may not be receiving the nourishment they require. The care plans are not used as a working tool, no one has oversight of the care that is delivered and no one is taking responsibility for maintaining good standards of care practice. As a result, staff are using the team leaders message book to pass on important information. For example, would it be possible to write in the care plans what time residents have tea and supper, paramedics needed to know and I couldnt tell them; Some residents are going to bed with bra and vests on which is leaving red marks and rubbing them, this has been mentioned before; can all staff make sure that when a resident is taken to bed their underclothes are taken off and washed. If they want to wear underclothes put clean ones on;can you make sure kitchen towels and table cloths arent washed with underwear and hand towels; check pockets before washing clothes as glasses found in washing machine. Important information about medication administration is also written in the team leaders message book instead of the care plans. We also found instructions about the application of topical creams, dressing changes,liquidiised diets, leg wounds, preferred portion sizes at meal times etc. People are not always treated with the privacy and dignity they deserve. For example,we saw a notice on display on a bedroom door which is on the main corridor where people enter and leave the building. The notice instructed all staff to wear aprons and gloves before entering the room because the occupant had MRSA. There was no information in the care plan about the action staff were expected to take to meet this persons needs and prevent cross infection. The hospital visit record in the care plan said phone call from hospital results from swabs saying (person A) has MRSA A note in the team leaders message book on 11/9/09 asked all staff to ensure that gloves and aprons are worn and ensure that bed is changed every day for five days and that this person is bathed every day for five days.There was no evidence in the records to show that advice had been sought from anyone with specialist knowledge about infection control. The member of staff said who made the entry in the team leaders message book said she had had experience of MRSA from previous work in a nursing home. No one is taking responsibilty to make sure there is an appropriate plan in place to manage the infection and make sure that appropriate action is taken by all staff. We could find no evidence in the care plan to show that this individual had been bathed. When we checked the water at the sink in this persons room,there was only an intermittant hot water supply. We also read a note in the team leader message book on 12/9/09 which said tap on bath in bathroom not working dont use because tap wont turn off. When we visited on 17/9/09 the tap was still not working. A member of staff told us about another individual who needed to have a regular bath because of a skin complaint, she said staff had carried pans of hot water from the kitchen to the bathroom to fill up the bath while the tap was not working in order to ensure that this person could have a bath. This is a serious risk to the health and safety of people living and working at the home. Because no one is taking responsibility for the day to day management of the home, the staff could not confirm whether any action was being taken to restore the hot water supply to the bathroom. They told us they record their requests for supplies and repairs Care Homes for Older People Page 6 of 15 in the team leader message book for a representative from WM Healthcare to action, but no one could tell us what action was planned. We asked a member of staff to contact WM Healthcare to request an urgent visit from a plumber, WM Healthcare confirmed that they had already done this and the plumber repaired the fault during our visit. We saw other entries in the records which said one of the tumble driers was not working; another entry said please dont use the washer or flush the toilets as theres a problem with the water;the toilet seats are loose. From the records we could not tell what action had been taken to repair the faults. At our last inspection in August 2009 we said the home was poorly maintained and many areas require redecoration and refurbishment to improve the facilities. We made a requirement for a refurbishment and redecoration plan to be put in place and a for copy of the plan to be sent to us by 30/9/09. Whilst we were on site we looked round the building and checked bedrooms, bathrooms and toilets. We found that there was no liquid soap in bathrooms and at wash hand basins. All bedrooms seen were not only in need of redecoration but some had peeling paintwork and staining to ceilings and walls. Some windows frames were badly stained and some of the double glazing units were filled with condensation. When we asked staff about laundry arrangements and how soiled laundry was transported around the home we were told of conflicting practises. One member of staff said laundry was collected in individual white baskets with clean laundry returned to bedrooms in indiviudal smaller baskets. She told us that soiled laundry is placed in red plactic bags. Another member of staff said she collected laundry in the white basket from more than one bedroom to take to the laundry. It is important that a consistant and established safe method of handling soiled laundry is in practise in order to ensure a high standard of hygiene and prevent cross infection. When we looked at the records in the team leaders message book we were concerned that staff are leaving notes for each other to pass on their concerns about cleanliness within the home. These are some of the messages we read to all staff - if they see faeces on the carpet in any room, clean it up faeces found on the floor near chair, can any faeces be cleaned up staright away please (person B) has been sick, cant mop the toilets, dont know where mop is; can someone check bathroom due to seeing lots of silverfish on the floor;bedroom smells of foist; did the best with cleaning but there isnt any cleaning stuff. We also looked at the bedrooms on the top floor which are currently unoccupied. We were very concerned to discover that several of the rooms are being used for the storage of unwanted furniture and archived records, creating a fire hazard. These bedrooms contained bed bases, discarded mattresses, zimmer frames, hoists, two washing machines, several mobile heaters, library books and boxes of archived records, and in one room a two seater sofa clearly marked not match resistant. Following our visit we reported our concerns to the Fire Officer.The Fire Officer has since informed us that this area has now been cleared. We checked the food stores located on the ground floor and checked in the freezers. We found one freezer containing a small amount of food. The bottom of the freezer was dirty with old bits of food. There were half opened packets of meat which we asked to be disposed of immediately because it may not have been safe for consumption. We were told that the home has a number of cooks and there is no one who takes overall Care Homes for Older People Page 7 of 15 responsibilty for checking food stores and cleanliness of fridges and freezers. The kitchen has been refurbished but is domestic in style. There were no dishwashing facilities and staff have to wash up everything by hand. At the key inspection on 9 February 2009 we reported that the registered provider had not made any arrangements to carry out monthly visits to the home and report on the conduct and management of the home. These visits must take place to check that the home is being managed properly and is being run in the best interests of the people living there. We made a requirement about this in our report from that visit, with a timescale for action by 20/3/09. No action was taken and we repeated this requirement in the report from our last key inspection on 7/8/09. We could find no evidence of any arrangements to carry out these reports on this inspection. This requirement has not been met. At the last key inspection on 7 August 2009, we could find no evidence of any current Employers Liability Insurance. The last certificate of insurance that was available expired in June 2009. We made a requirement for a copy to be sent to the Commission by 19 August 2009. We have not received a copy of this document and the certificate was not on display when we carried out this inspection on 17 september 2009. This requirement has not been met. We also made a requirement in the report from 7 August 2009 that all of the equipment in the home must be serviced and in good working order so that peoples health and safety is not placed at risk. We could not find any records of servicing on this inspection therefeore this requirement has not been met. At the inspection on 7 August 2009 we were concerned that staff had only a limited understanding of the accident procedure and there was evidence that some accidents had not been recorded. We made a requirement that a record must be kept of all accidents that occur. On this visit we found evidence of accidents recorded in the seniors communication book but we were unable to locate any associated accident records. This requirement has not been met Also at the last key inspection in 7 August 2009 we found evidence of staff starting work at the home before appropriate checks had been carried out to confirm their suitability. The records also revealed that some of the CRB checks (Criminal Records Bureau) held on staff files were up to six years old. We made a requirement in the last report that all staff must be appropriately checked before they start work at the home to ensure they are suitable and that people living at the home are safe. WM Healthcare took steps to suspend those unchecked staff pending receipt of satisfactory CRB disclosures and made arrangements to renew all CRBs that were more than three years old. This requirement has been met. What the care home does well: What they could do better: The provider must take action to make sure that the home is run and managed in the best interests of the people who live there. This must include: Care Homes for Older People Page 8 of 15 Making sure that the health, safety and well being of people is protected and promoted. Making sure that peoples care plans tell staff everything they need to do to support that person. Making sure that the plans are reviewed regularly and reflect the care that people need. Making sure that there are always enough staff on duty to look after people properly. Making sure that staff receive the training they need to equip them to do their job properly, understand peoples needs and how to meet them. Making sure the home is kept clean at all times so that it is a pleasant place for people to live. Making sure that the home is being managed properly. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 9 of 15 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 Care plans and risk assessments must be kept up to date and reviewed regularly. This is an outstanding requirement from 24 January 2008. This is to make sure that people receive the care and support they require. 20/03/2009 2 7 15 Care plans must be in place that address peoples ongoing health care needs. This will make sure they get the treatment they need. 20/03/2009 3 8 12 People must be weighed regularly and nutritional assessments and food and fluid intake must be monitored regularly. This is an outstanding requirement from 24 january 2008. This is to prevent the risk of people being malnourished. 20/03/2009 4 18 13 Staff must receive appropriate training to ensure that they are aware of their responsibility to safeguard people in their care. 20/03/2009 Care Homes for Older People Page 10 of 15 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action To ensure that people using the service are safe and protected from abuse. 5 19 23 A redecoration and refurbishment plan must be put in place with clear timescales for work to be carried out. A copy of the plan must be sent to the Commission by 30/9/2009. This will make sure the home is brought up to standard. 6 30 18 All staff must receive training 30/09/2009 which is appropriate to the work they are to perform. To ensure that staff are competent and trained to care for peole in a safe manner. 7 33 26 Arrangements must be made 20/03/2009 to carry out monthly visits to the home and make monthly reports available about the conduct of the home. To ensure the home is being run in the best interests of the people living there. 8 33 24 A quality assurance system must be established to seek the views of people who use the service. This will give people the opportunity to comment on the service provided and say if it could be improved in any way. Care Homes for Older People Page 11 of 15 30/09/2009 30/09/2009 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 9 34 25 The correct and current 19/08/2009 Certificate of Employers Liability Insurance must be in place and a copy sent to the Commission. This is to cover legal liabilities to employees, people living at the home and third parties. 10 36 18 Arrangements must be in 30/09/2009 place to ensure that staff are appropriately supervised. To identify training needs, monitor care practice and provide staff with support 11 37 17 The homes records and 30/09/2009 policies and procedures must be kept up to date. To safeguard peoples rights and best interests. 12 38 8 All of the equipment used in the home must be serviced and in good working order In order that peoples health and safety is not placed at risk. 31/07/2009 13 38 13 A plan must be in place with clear timescales to address the health and safety issues that have been identified. A copy must be sent to the Commission by 30/9/2009. To protect and promote the health and safety of people living at the home. 30/09/2009 Care Homes for Older People Page 12 of 15 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 14 38 17 A record must be kept of all accidents that occur in the home. To monitor when and where accidents are taking place and put in place preventative action 07/09/2009 Care Homes for Older People Page 13 of 15 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 30 13 All staff must receive 30/10/2009 appropriate training in infection control procedures. This is to prevent the spread of infection in the care home. 2 31 38 You must inform the 06/10/2009 Commission about the management arrangements that have been made for the running of the home. So that there is someone in day to day control to ensure that the home is being run in the best interests of the people living there and to ensure that people receive the care they need. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 14 of 15 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 15 of 15 - 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!