Inspection on 04/12/07 for Sue Ryder Care Birchley Hall

This inspection was carried out on 4th December 2007.

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

Sue Ryder Care Birchley Hall 08/01/07

Sue Ryder Care Birchley Hall 19/07/05

Sue Ryder Care Birchley Hall 13/06/05

Sue Ryder Care Birchley Hall 09/12/04

Sue Ryder Care Birchley Hall 24/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Sue Ryder Care Birchley Hall Birchley Road Billinge Wigan WN5 7QJ Lead Inspector Mrs Lynn Paterson Key Unannounced Inspection 9.30 4th December 2007 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 Sue Ryder Care Birchley Hall DS0000022399.V347910.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. Sue Ryder Care Birchley Hall DS0000022399.V347910.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sue Ryder Care Birchley Hall Address Birchley Road Billinge Wigan WN5 7QJ 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) 01744 894893 01744 895430 ursula.scarff@suerydercare.org www.suerydercare.org Sue Ryder Care Margaret Ursula Scarff Care Home 31 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (31), Physical disability (31) of places Sue Ryder Care Birchley Hall DS0000022399.V347910.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only: Old age, not falling within any other category: Code OP (maximum number of places: 31).. The maximum number of people who can be accommodated is: 31. Date of last inspection 8th January 2007 Brief Description of the Service: Birchley Hall Care Home is registered to accommodate up to 30 older persons 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 lift. Communal rooms include 3 lounge areas, spacious dining room and a conservatory. Fees are currently £372------£403 per week. Sue Ryder Care Birchley Hall DS0000022399.V347910.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information about Sue Ryder Care - Birchley Hall was obtained through a pre inspection questionnaire a site visit and examination of the homes policies and procedures and supporting documentation. Completed questionnaires were also received from staff and representatives of people who used the service. Discussions took place with people living in the home, the registered manager and members of the staff teams. A tour of the premises was undertaken and staff and residents observed during their interactions. What the service does well: What has improved since the last inspection? Pre admission assessments and care planning documentation has been monitored and reviewed and changes made as appropriate. Staff training has been enhanced and records show that 73 of staff has NVQ qualifications and a further 20 are currently undertaking NVQ courses. Quality monitoring groups have been introduced to include staff attending professional forums to ensure that the home maintains high standards of care and services provision for the people living therein. Sue Ryder Care Birchley Hall DS0000022399.V347910.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sue Ryder Care Birchley Hall DS0000022399.V347910.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 Sue Ryder Care Birchley Hall DS0000022399.V347910.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): 1.3. Quality in this outcome area is good. Residents are only provided with a service after their needs are assessed and they are assured their needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home said they had been provided with information about the services provided prior to them making their minds up if they wanted to stay there or not. Three residents said that this enabled them and their families to make informed choices about the future. Records show pre admission assessments are undertaken on all prospective residents prior to them being offered a placement. Care files viewed show that Sue Ryder Care Birchley Hall DS0000022399.V347910.R01.S.doc Version 5.2 Page 9 prospective residents, their families/representatives are all fully included in the pre admission process. Staff said an assessment of residents care needs is always carried out prior to an offer of a placement being made. They say that this enables staff to have sufficient information for them to know if they have the staff, experience and resources to meet all assessed need. This includes issues relating to equality and diversity, age, disability, gender, race, religion, sexuality mental capacity and cognitive skills. The manager advised that risk assessments are completed to ensure residents safety and welfare and they are updated as an ongoing process. Sue Ryder Care Birchley Hall DS0000022399.V347910.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. Quality in this outcome area is excellent. The personal and health care needs of the people living in the home are monitored and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans viewed were clear and very detailed. They identified all individual care needs and described how each need would be met, when it would be met and by whom. Staff said the care plans were devised to look at the whole person and their holistic needs. Resident’s health care needs are monitored and reviewed with a record of their daily welfare being kept. Residents said they were able to tap into all health care services as needed with GP’s, Dentists, chiropodist, district nurses calling at the home by request. It was noted that a speech therapist was visiting a Sue Ryder Care Birchley Hall DS0000022399.V347910.R01.S.doc Version 5.2 Page 11 resident for consultation and records show many health care professionals are frequent visitors to the home. The manager advised that she was in the process of developing a strategy for the management of challenging behaviour with a view to amending care plans and providing training to staff on how to record details of residents behaviour. The manager said that past practices had been mainly to concentrate on resident’s physical needs. However care reviews and reassessments had highlighted that mental health needs also need to be addressed and strategies implemented to ensure that staff see each resident as a whole person and meet all assessed need accordingly. Residents spoken with said they were treated well by staff and comments included-: “The staff are very kind and helpful” “I have lived here for some time now and the staff have stayed the same. They seem to know exactly what I need and when I need it, they are grand”. The manager said she makes sure that residents are asked about their views of the standard of care provided to them by speaking with them individually and also by holding residents meetings to check out the feelings of the people living in the home. Examination of Policies and procedures written to promote the social inclusion of those receiving care included the sexuality and relationship policy, the equal opportunities policy, the individual planning and review policy and the referral and admission policy. These documents showed that equality and diversity issues were well managed within the home. Medication records and storage systems examined and were well managed and staff spoken with exhibited good knowledge of how to handle medication. Staff training records confirmed that staff are provided with ongoing training in all aspects of medication. Sue Ryder Care Birchley Hall DS0000022399.V347910.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. Quality in this outcome area is excellent. The homes routines are flexible and provide excellent choices for the people living in the home in all aspects of daily life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans show that social care is incorporated into residents care plans and the activities programme revealed that activities are provided each day. However it was noted there was inconsistency in the recording of individuals’ daily activities or social interactions. Care files held an activity sheet, which the manager said should be completed each time a resident attends an activity but the sheets viewed held little detail of when the people living in the home participated in an activity or interest. This was discussed with the manager and it was agreed that all aspects of daily life should be recorded to ensure that records show a true picture of people daily life. Residents spoken with confirmed that activities were arranged and said they had recently enjoyed an outing to a tea dance and six residents had been invited out to a church Christmas lunch that day. Sue Ryder Care Birchley Hall DS0000022399.V347910.R01.S.doc Version 5.2 Page 13 Record show that social activity and menu planning are part of the agenda at each monthly resident meeting’s and people living in the home said they could air their views and make recommendations for changes if so wished. Residents said they could come and go as they pleased and could live their life as they wished, within reason. They confirmed that their relatives and friends could visit at any time and were always welcomed into the home. The dining room has benefited from redecoration and refurbishment of furnishings and presented as bright airy and most comfortable. Residents said they thought the food was wonderful and comments included: “How do they always manage to get the food just right”, “I have never had a bad meal yet and I have been here forever”, “The menus are good and varied and we get plenty of everything” “The food is truly wonderful”. Observations of residents eating lunch revealed that staff provided discreet assistance to people who had difficulty eating their food. This assistance was provided by staff that at all times showed awareness of respecting the dignity of the person being assisted. Small meals. Liquidised food, beakers and various forms of cutlery were provided as appropriate. A sample meal tasted whilst joining the residents at lunch- time totally confirmed that the food provided in the home was tasty, wholesome and most delicious. Staff advised that they realise that mealtimes are an important part of the day to provide residents with interest and stimulation and an opportunity to mix and communicate with other people living in the home. Staff said they do their very best to ensure that each mealtime is a time for people to relax in a pleasant surroundings and enjoy the occasion. Sue Ryder Care Birchley Hall DS0000022399.V347910.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. Quality in this outcome area is good. Systems are in place to ensure the protection of residents from abuse or harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pre inspection questionnaire revealed that the home had received no complaints within the past 12 months and no concerns have been made to CSCI. The home uses a complaints process, which is clear and all staff and people living in the home said they knew about the complaints policy and would use it if they ever needed to. Staff spoken with exhibited full understanding of the protection of vulnerable adults and demonstrated knowledge of the different types of abuse that can take place. Staff training records further evidenced that all staff receive on going training in all aspects of Adult Protection. Sue Ryder Care Birchley Hall DS0000022399.V347910.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): 19.25.26. Quality in this outcome area is excellent. The home is well maintained and provides a safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The overall standard of the premises is excellent with maintenance work being carried out as an ongoing process to ensure the home is always fit for purpose. Fabrics and furnishings are of a high standard and staff, ensure that the home benefits from pictures, plants and ornaments being placed around the building. People living in the home say they are happy and content with all the services and feel safe and secure. They say that if a light bulb ceases to work it is replaced immediately and any other matter that needs attention are attended to right away. Sue Ryder Care Birchley Hall DS0000022399.V347910.R01.S.doc Version 5.2 Page 16 The home provides adequate bathing and toilet facilities, which are well maintained and provide appropriate aids and adaptation to enable people living in the home to bathe in safety and comfort. Although the laundry area had suffered an enormous water leak just prior to the day of the visit, it was clean and well organised and had systems in place to prevent the spread of infection. Gardens and grounds are very well looked after and gardeners were spoken with. They displayed great pride in their work and said they took pleasure in making the grounds safe and welcoming for the people living in the home. The main entrance to the home is situated away from the staff room and managers office and as a consequence people can come and go from the home without being observed. This was discussed with the manager and whilst it is not seen to be a shortfall of the service it was agreed that some kind of monitoring system would be of benefit. The manager said she would consult with Sue Ryder Care organisation with a view to exploring the possibility of using CCTV on the outside of the entrance. People living in the home said they were very happy with the standards in the home and advised that it was always maintained to a very high standard, was very clean and smelled nice at all times. Comments included: “Staff must work very hard to keep this place as nice as it is”, “The domestics and maintenance men are always cleaning, decorating or doing something to keep the very high standards up. This home is like a palace.” Sue Ryder Care Birchley Hall DS0000022399.V347910.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.Quality in this outcome area is excellent Staff recruitment and selection and training programmes ensure staff, are suitable and competent to carry out their role. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information contained in the pre inspection questionnaire indicated that staff have completed a range of training this year and further training in planned as an on going process. Records show 73 of staff has VVQ qualifications and a further 205 of staff are working toward the award. The manager advised that staff turnover is very low and staff and people living in the home benefit greatly from the consistency and continuity of care. Staff said they are provided with “a passport to practice”. This is a document that holds a record of all training courses attended and is a true record of personal achievement. Staff spoken with said they felt empowered by the training which was available through the home and by the inclusive nature of the line management. They said they were asked their opinions about staffing levels, policies and procedures and training and made to feel valued as people as well as members of staff. Sue Ryder Care Birchley Hall DS0000022399.V347910.R01.S.doc Version 5.2 Page 18 Staff files examined held all the required information to include relevant references and police checks and full employment history. Staff said they had been provided with induction training when they were first employed and all new staff is now provided with mentorship and support. The manager advised that Sue Ryder Care organisation have provided a Lead person to carry out Education and training at Birchley Hall one day per week which she sees as enabling all staff to be proved with updated information about good practice issues. Staff revealed in discussion and by feedback form questionnaires, they enjoyed their work and felt supported in their roles. The general consensus from staff was that they worked together as one big happy family. Sue Ryder Care Birchley Hall DS0000022399.V347910.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): Quality in this outcome area is excellent. 31.33.35.38. The home is well managed to ensure residents welfare and comfort is maintained and to maximise services. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is very experienced in the care of older people. She is qualified to NVQ level 3, has achieved her Registered Managers Award and Risk & Safety Management Award. She advised that she feels she has to constantly update her own knowledge and skills in order to keep up with constantly changing processes and as a consequence had enrolled on further educational programmes to help her achieve her aim. Sue Ryder Care Birchley Hall DS0000022399.V347910.R01.S.doc Version 5.2 Page 20 Staff said they are clear lines of accountability in the home and say that many changes have been implemented in the management structure of the home over the past year. Staff say they receive pre planned structured supervision, clearly detailed appraisals, have been provided with personal training passports, have been trained and supported to have more delegated powers in recording and decision making and feel valued in their roles. The pre inspection questionnaire details the range of policies and procedures in the home relating to the care of residents and the running of the home and discussions with the manager and staff revealed that all policies have been monitored and reviewed and find tuned where necessary. Record show a representative from Sue Ryder Care visits the home on a regular basis and carried out a quality assurance audit. Details of the outcome are then sent to CSCI. The home manager also attends a quality management group, which meets to ensure that any improvements that are needed are discussed and acted upon. Resident’s health, safety and welfare are promoted in the home. The pre inspection questionnaire revealed that all equipment and essential services are tested on a regular basis. Various testing of services was observed on the day of the visit to include alarm testing and emergency lighting systems. Staff advised they have all completed health and safety training and revealed that a health and safety checklist is completed each week to ensure everything is in order. Sue Ryder Care Birchley Hall DS0000022399.V347910.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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 4 4 STAFFING Standard No Score 27 3 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Sue Ryder Care Birchley Hall DS0000022399.V347910.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. 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. 2 Refer to Standard OP7 OP7 Good Practice Recommendations It is suggested that individual care files hold full detail that accurately reflect daily life to include resident’s participation in activities and interests. It is suggested that care files hold detail of residents past history to enable staff to engage in meaningful conversations with people living in the home. Residents said they would welcome this as their past brings back pleasant memories and stimulates their minds. It is suggested that a monitoring system be installed at the main entrance of the home to ensure all people entering and leaving the building are observed. 3 OP19 Sue Ryder Care Birchley Hall DS0000022399.V347910.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Sue Ryder Care Birchley Hall DS0000022399.V347910.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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