CARE HOMES FOR OLDER PEOPLE
Strawberry Bank 17 Strawberry Bank Liversedge West Yorkshire WF15 6JT Lead Inspector
Karen Summers Key Unannounced Inspection 4th July 2006 09:45 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.V290671.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.V290671.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 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.V290671.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 19th October 2005 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. Fees at the home start at £332.98 - £344.71 per week. Items not covered by the fee include: Newspapers, magazines and hairdressing. Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report refers to a key inspection, which included an unannounced site visit on the 4th July 2006, and the duration of the site visit was 6 hours. There were 20 service users in residence on the day. Miss Claire Allen, manager, was present throughout the inspection. The following areas were looked at and have been used in the production of this report; a sample of records, care plans, medication, individual discussion with 5 service users, 2 members of staff, tour of the premises and document reading. To reflect the views of those who use the service, satisfaction questionnaires were sent to: 10 service user, 4 were returned; 10 relatives, 7 were returned, 6 GP practices, none were returned, and 2 district nursing teams, none were returned. The inspector would like to thank those who contributed to the inspection process, and also thank Miss Allen, her staff, service users and their relatives, for their time and hospitality on the day of visit. What the service does well:
Care records have greatly improved since the last inspection, and Claire Allen, manager, should be complimented on her hard work in updating the documentation, which was of a good standard. A varied and stimulating activity programme is published every four weeks and service users are invited to participate in any of the events advertised. The information is distributed to relatives and prospective service users and is also displayed around the home. It is also available in large print, floppy disc or on tape. Activities include; beauty therapy, crafts, bingo, individual activities, going out for a walk, dominos, quiz visit to the garden centre and many more. Service users said how they enjoyed their time visiting the home, and that the food was also enjoyable. Consideration is given to people with visual impairments and links are maintained with the Blind society, who every other day sends to the home talking books, magazines and newspapers. Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Strawberry Bank DS0000063274.V290671.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.V290671.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 No service user moves into the home without having had his/ her needs assessed and been assured that those needs will be met. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Prospective service users and their relatives are encouraged to have a look around the home, and spend some time there before deciding to move in, and this was confirmed by a service user who was spoken with. Service users are admitted following an assessment of their needs that is undertaken by the manager or a senior carer, and to which the prospective service user, his/ her representative (if any) and relevant professionals have been party. The manager then confirms in writing that the home can meet their needs.
Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 The service users’ health, personal, and cultural needs are set out in a plan of care, and they receive the level of support they require to ensure that those needs are maintained. Service users are protected by the home’s policies and procedures for dealing with medicines. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care records have greatly improved since the last inspection, and were of a good standard. The daily record was comprehensive, and gave an account of the care given that day, and also included the activities that the service user took part in. Two of the service user questionnaires said that they always receive the care and support they need, and one commented, “The carers are very good.” This was also reflected in what the service users said when spoken with. Without exception, the relatives/ visitors comment cards stated, that they are satisfied
Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 10 with the overall care provided. One commented that the care was good, and “… the home is only as good as the carers…” Medication housekeeping was of a satisfactory standard, should a service user wish to self- administer their medication, there is a risk assessment and documentation. Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 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 - 15 Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, religious and recreational interests and needs. The needs of those service users who have a visual disability are supported. A variety of meals are offered that take into account the likes and dislikes of the service users and their religious and medical needs. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A varied activity programme is published in large print each week and it is displayed in the home. Then staff each day individually invites service users to participate in the advertised events. The service users who were spoken with said that activities did take place, and they included: listening and singing along to music, painting, hand massage, listening to talking books, reminiscence, dominos and cards, crafts, and going out to places of interest, e.g. Tropical World, strawberry picking, and swimming. One of the service users holds a church service at the home every week, and she also visits and maintains contact with her own church.
Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 12 Consideration is given to people with visual impairments and links are maintained with the Blind society, who every other day sends to the home talking books, magazines and newspapers. The menus offered a variety and choice of food, and individual service users food preferences; specialised diets and cultural needs had also been taken into consideration when planning the menus. Service user questionnaires generally stated that the food was always good. One questionnaire stated that they “can’t complain about the meals”, and another said that the food was not bad, but a lot of the same thing. A service user who was spoken with said that the food was fantastic. Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Service users and their relatives can be confident that their complaints will be listened to, taken seriously and acted upon in a timely manner. Service users are protected from abuse. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There is a simple complaints procedure, which specifies how complaints may be made, and includes the stages and timescales for the process. The procedure, upon request would be produced in large print. Four out of seven relatives comment cards stated that they were not aware of the complaints procedure. Ms Allen said that she now gives a copy of the complaints procedure to each relative/ service user at the time of admission. There is also a whistle blowing procedure, and staff receive abuse awareness training. Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22.3, 25.5 & 26 The owner has started to improve the environment for the service users, however a number of areas are still in need of redecoration, and replacement of furniture. Until all radiators in service user areas are appropriately guarded, service users are potentially at risk of being burnt. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A number of service users rooms were showing signs of wear and in need of redecoration and refurbishment. The main entrance corridor carpet, even though it has been replaced in the last year, looked thin and dirty, and the lounge chair arms were also looking worn and dirty. The basement entrance hall (not used,) wall coverings were showing signs of wear and in need or redecoration, and this was pointed out at the last inspection. The laundry room floor covering was damaged and needs replacement, and the wall covering was
Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 15 flaking and could not be properly cleaned. The registered person is requested to send to the Commission a copy of the redecoration programme, and consideration should also be given to a programme of replacement bedroom furniture. The guarding of radiators in service user areas has commenced. The radiators in corridors should not be used until they have been guarded, as there is a risk that a service user may use the radiator to balance, or someone could fall against them and be burnt. The manager said that she was in the process of revising the radiator risk assessment and would send a copy of it to the Commission. The registered person is also advised to provide grab rails in corridors. Staff have had the Control of Infection training, and the majority of satisfaction questionnaires from service users said that the home is always fresh and clean. Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 The staffing levels and skill mix were sufficient to meet the number and needs of service users. Staff are trained to do their jobs. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There were 20 service users in residence and the staffing levels and skill mix were sufficient to meet the number and needs of service users. Three relative satisfaction questionnaires stated, that there were insufficient staff on duty, and the remaining four questionnaires said that there was always enough staff on duty. Service users questionnaires stated that there was usually enough staff available when you need them. Fifty percent of care staff have an NVQ level 2, and staff that were spoken with said that they had induction training within 6 weeks of employment. The information and documentation in relation to recruitment was correct however, care should be taken to ensure that any gaps in employment records be explored. Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38 Once the manager has completed her training she should have the knowledge to efficiently manage the home. Service users’ financial interests are safeguarded. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Claire, the manager, has a number of years experience in the care of older people, and she has nearly completed the registered managers award, and then hopes to complete an NVQ level 4. Quality assurance and quality monitoring systems are in place based upon seeking the views of service users and their relatives, to ensure that the home is run in their best interest.
Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 18 The audits of service users’ finances were correct. The supervision of staff has commenced, and planned to take place approximately every two months. All staff have movement & handling training and the manager ensures that there is always a member of staff qualified in first aid on duty. The home has a fire facilitator, and staff have had fire lectures and drills, and the emergency lighting and alarm tests are carried out weekly. Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 1 X X 2 X X 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23.-(2)(d) Requirement The registered person shall ensure that all parts of the home are kept clean and reasonable decorated. The registered person is requested to send a copy of the redecoration programme to the Commission. Timescale for action 07/08/06 Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations The lounge chairs should be cleaned/ replaced. The corridor carpets should be cleaned/ replaced with a more serviceable carpet. • There should be a plan of replacing bedroom furniture. 22.3 – The home should provide grab rails in corridors. 25.5 - The guarding of radiators in service users areas should be completed as per schedule. 26.4 – The laundry floor finishes should be impermeable and wall finishes cleanable. 29.2 – Any gaps in employment records should be explored. Standard 31.2 - The manager should have an NVQ level 4 in management and care or equivalent. • • 2. 3. 4. 5. 6. OP22 OP25 OP26 OP29 OP31 Strawberry Bank DS0000063274.V290671.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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