CARE HOMES FOR OLDER PEOPLE
Sue Ryder Care Birchley Hall Birchley Road Billinge Wigan WN5 7QJ Lead Inspector
Lynn Paterson Unannounced 19th July 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. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Sue Ryder Care Birchley Hall Address Birchley Road Billinge Wigan WN5 7QJ 01744 894893 01744 895430 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) Sue Ryder Care Mrs Des Reynolds Care Home 30 Category(ies) of DE - Dementia registration, with number OP - Old Age of places PD - Physical Disability Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 30 (OP); 30 (PD) over the age of 55 years; 2 (DE) 2. that staff are provided in sufficient numbers and skill mix to meet the assessed needs of all service users. Date of last inspection 13th June 2005 Brief Description of the Service: Birchley Hall Care Home is registered to 30 older person who are in need of assistance with their personal and social care. The home forms part of The Sue`Ryder organisation and is situated in a residential area,close to shops and local amenities and is set within extensive grounds affording views over open countryside. The premises comprise 24 single and 3 double bedrooms,most of which have en-suite facility. Accommodation is provided over three floors with upper floors being accessible via a passenger lft. Communal rooms include 3 lounge areas, spacious dining room and a conservatory. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over a 3- hour period and was made as a follow up to an earlier inspection carried out on 14.06.05. The second visit was made to address standards 14,29,31,32,33 and 38, which had not been assessed at the previous inspection and to meet with the home manager and her deputy. A partial tour of the premises took place and staffing and health and safety records were examined. Four of the staff on duty, twenty -six of the residents and the manager and her deputy, were spoken with. What the service does well:
Residents spoken with stated that they were well looked after by caring and professional staff in a very well maintained environment. Residents comments included “the staff really care about us all”, “we are lucky to be in this home as it is so good”. “we are treated very well” ”the home is always well decorated and clean”, ”we sit in the gardens which are always kept so nice”. ” food is great” we are given full choice in all we do and treated with respect at all times”. Staff records showed that staff training is ongoing staff are encouraged to achieve NVQ care qualifications. The home has recently been awarded The Investors In People award and staff appeared motivated and encouraged by this. The home has produced clear and direct protocols for reporting and communicating need to know information and staff advised that they found the systems to be useful and fail safe. Staff and residents spoken with said that the management of the home was excellent. It was noted, through discussion and reading of documentation that the management team in partnership with Sue Ryder Care Organisation are constantly striving to find innovative methods to meet changing needs of all individuals in their care. Health and safety policies, procedures, risk assessment and recording systems were of a high quality at the time of the inspection visit. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 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. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 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 Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 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) Standards assessed at the previous inspection. EVIDENCE: Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 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) Standards assessed at the previous inspection. EVIDENCE: Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 Page 10 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) 14 Residents are assisted by staff to exercise choice and control over their lives. EVIDENCE: Care plans showed that they had been developed in partnership with residents and their representatives and held clear information about choices, preferences and capabilities. Risk assessments were also in place to make sure that risk could be addressed and managed and that residents could make informed choices about their lives and wherever possible, take control. All residents spoken with revealed that their daily living was arranged according to their choice and comments made included” we do as we wish”,” we are helped to do the things that we cannot do but we choose what help we need”” we come and go as we please”,” staff are around to assist when we want them to”,” we are given choices in everything here”, “if we want to do it, we do it, if we don’t want to do it we don’t do it.” Residents also said that staff were very kind and knowledgeable about their needs and offered assistance only when necessary. Residents stated they felt they were consulted about everything involved with their life. Staff training records identified that all staff had received training in general care practices to include choice, inclusion and dignity. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 Page 11 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) Standards inspected at the previous inspection. EVIDENCE: Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 Page 12 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) Standards inspected at the previous inspection. EVIDENCE: Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 Page 13 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) 29 Residents are supported and protected by the homes recruitment policy and practices. EVIDENCE: The home use a corporate Sue Ryder Care recruitment and selection policy which determines that all necessary recruitment checks are carried out prior to appointment to ensure the protection of residents. Staff files held criminal records bureaux checks and clear references. Staff advised that they had full knowledge of the recruitment and selection process to include how this system assisted to ensure the protection of residents. Records showed that staff turnover was very low and staff received full training in all aspects of safe care. Residents spoken with said that they were well looked after by staff who always treated them with respect. Staff spoken with said that they were encouraged to participate in ongoing training and self- development and had recently had their positions harmonised in line with NHS agenda for change. Staff commented that they felt valued and motivated by this process as the pay structure was now the same throughout Sue Ryder Care Organisation. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 Page 14 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) 31.32.33.38. The management team provide leadership guidance and direction to staff to make sure that residents receive consistent quality care. The health, safety and welfare of all staff and residents is promoted and protected by clear policies, procedures and practices. EVIDENCE: Staff spoken with commented that the management and leadership of the home, was of a high quality with all need to know information being shared at meetings and staff handovers. Residents spoken with revealed that they felt valued and supported by the management team. Residents comments included “ we feel very much a part of this home”, ”we feel that this is our home”,” we always know what is going on here”, ”staff tell us everything that is happening”. Minutes of staff and residents meeting showed that discussions were held to ensure that residents were kept informed and consulted about the running of the home and that the home was run in the best interests of all who resided at Birchley Hall.
Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 Page 15 Health and safety policies and procedures and records viewed revealed that the health, safety and welfare of residents and staff was promoted and protected. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 Page 16 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 4 15 x
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 4 4 3 x x x x 4 Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 Page 17 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 Regulation Requirement Timescale for action 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 12 Good Practice Recommendations It is recommended that chair line dancing be introduced into the homes activities programme as per residents request. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V241533 190705 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection Burlington House Crosby Road North Waterloo, Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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