Inspection on 16/02/06 for The Hurstway

This inspection was carried out on 16th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Hurstway 13/07/09

The Hurstway 19/07/07

The Hurstway 20/09/06

The Hurstway 17/10/05

The Hurstway 10/02/05

The Hurstway 02/06/04

The Hurstway 04/02/04

The Hurstway 21/10/03

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

CARE HOMES FOR OLDER PEOPLE Hurstway, The 142 The Hurstway Erdington Birmingham West Midlands B23 5XN Lead Inspector Kath Strong Unannounced Inspection 16th February 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 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. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hurstway, The Address 142 The Hurstway Erdington Birmingham West Midlands B23 5XN 0121 350 0191 0121 386 4225 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) Heart Of England Care Ms Marie Ann Swadkins Care Home 59 Category(ies) of Dementia - over 65 years of age (59), Physical registration, with number disability over 65 years of age (59), Terminally of places ill over 65 years of age (59) Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That Marie Ann Swadkins successfully obtains the registered Managers Award or equivalent by April 2005 That the home can accommodate a total of 59 people of which up to three persons are over 60 years of age but under 65 years of age in line with their categories of registration. 17th October 2005 Date of last inspection Brief Description of the Service: The Hurstway is a purpose built home located in a residential area of Birmingham, and owned by The Heart of England Care charity. The home is registered to provide nursing care for up to 59 older adults. All bedrooms are for single occupancy with shared bathroom and toilet facilities. The accommodation is laid out over 2 floors, in 4 separate units, known as Primrose, Bluebell, Lavender and Jasmine, each unit having a lounge/dining room for residents to circulate. Downstairs there is a reception area with chairs and settees, which the residents have the use of. There are ranges of aids and adaptations designed to accommodate residents with limited mobility, including a shaft lift between floors, a call system, grab rails and assisted bathing and toilet facilities. A variety of well cooked and presented nutritious meals are provided, with alternative choices available if requested. At the front of the building is a car park for visitors, and at the rear is an enclosed garden, which provides a safe area for people to frequent during clement weather. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to conduct an unannounced inspection, the outcome of which was determined by various means. In the main the inspection focussed upon the requirements generated form the last inspection and any standards deemed necessary. Relevant documentation was examined including four care plans, one of which was case tracked in order to ensure that all identified needs were being met. Staff training and the food menu were assessed and a partial tour of the premises was carried out. In depth discussions were held with the registered manager and the deputy manager. Individual discussions were held with three residents. At the conclusion written and verbal feedback was provided. What the service does well: What has improved since the last inspection? Two units have been redecorated and carpets replaced in communal areas. Two specialist chairs have been purchased. A new stock of bed quilts, quilt covers, pillows, pillow protectors and towels have been acquired. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 Page 6 A maintenance programme for the year has been collated. Paper hand towels, dispensers and soap dispensers have been installed in all bedrooms. A washing machine has been replaced with one of a higher capacity and sluice cycle. Twelve electric profiling beds have been ordered and are due to arrive shortly. A new hoist has been ordered which will increase the complement to five. The fire alarm system was being upgraded at the time of the 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. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 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 Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 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): 2 and 3 Following admission residents are provided with a contract of terms and conditions. The pre-admission assessment tool is adequate but staff must fully document their findings. EVIDENCE: The content of the contract of terms of residency was found to be satisfactory. Pre-admission assessments are carried out in order to ensure that the home can meet all of the identified needs. Improvements were noted regarding completion of the tool, however the home is required to ensure full details are recorded. Standard 4 was assessed at the last inspection and was fully met. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 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 and 11 Some further development of care plans is required to ensure that the home fully meets all identified needs of residents. There is good evidence of the involvement of external professionals. Medication practices were found to be robust in ensuring that residents are not put at risk. Staff practices observed ensured that the privacy and dignity of residents is respected. EVIDENCE: Care plans contained assessments, care planning, risk assessments and regular reviews. The documentation in respect of wound care, foot care, communications, sleep patterns and medication was found to be comprehensive. Further development of files is required. The family background and life history must be documented and used as a tool for preferred activities and as an indicator in instances when inappropriate behaviour is displayed. Staff must have written guidance of likely triggers, the usual behavioural pattern and how staff should deal with instances of inappropriate behaviour. These are considered to be important factors in the care of persons with dementia and will positively reflect the registration category of the home. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 Page 10 The file of one resident indicated that she was awaiting an operation but it was impossible to determine the rationale, a care plan needs to be developed for this. The home must be able to cross reference letters and reports with the documents held separately on wound care. The practice in respect of generic documentation of death and dying must cease and should be individualised. The risk assessments and staff instructions for manual handling needs were clearly documented. The management section of the tool should be completed to advise staff of day to day requirements. The falls risk assessments do not need to include instructions for mobilisation. The records made by key workers failed to provide useful or relevant information and needs to be reviewed and staff training carried out. The home is advised that risk assessments should be carried out only for those residents who require the assistance of bed rails or use of wheelchairs. There appeared to be good and proactive relationships with external professionals to enhance the home in meeting the health care needs. The system for the administration of medications was examined on the upper floor of the home and found to be satisfactory. The documentation and auditing of receipt of new supplies and carrying forward process were good and there is a contract in place for the disposal of unused items. The file included the monitoring tool for those residents suffering from diabetes. Staff practices regarding maintaining the privacy and dignity of residents did not raise any concerns and staff were observed using residents preferred term of address. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 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 and 15 The home is unable to demonstrate that the activities programme has taken into account resident’s preferences. The meal menu does not indicate the various options that the home offers residents. EVIDENCE: As discussed earlier care plans do not include background details of residents to facilitate staff in providing an activities programme to reflect individual’s preferences. The section of the care plan entitled social care planning is not being completed. The home needs to address these issues in order to evidence that the current programme is suitable for the majority. The remainder of this standard was not assessed on this occasion. Examination of the menu provided limited information for the main meal of the day. The lunchtime menu consisted of three courses including an alternative for the main course, which in the main were fish or breaded foods. Advice was given that other meals as well as the two items listed were offered when alternatives are requested. The home needs to review and collate a menu, which clearly indicates the number and varied choices available for the main course of the day ensuring that these are age appropriate and to indicate that a variety of fresh fruit and vegetables are offered. The presentation of meals served was not assessed on this occasion. Those residents spoken with raised no concerns. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 Page 12 Standard 14 was assessed at the last inspection and was fully met. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 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 The complaints procedure is readily accessible and concerns raised are investigated appropriately. EVIDENCE: Examination of the complaints file indicated that the home receives relatively few and those received had been investigated and resultant action taken as necessary. Standard 18 was assessed at the last inspection and was fully met. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 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, 20, 21, 24 and 26 Residents are provided with warm, comfortable and well maintained accommodation. Bedrooms although restrictive in size are furnished and decorated to a good standard. EVIDENCE: There are two lounge/dining rooms on each of the floors offering choices for residents to frequent. The four sections of the home provide appropriate layout for the category of the registration. All areas visited were found to be tidy, clean and odour free. The registered manager advised that due to the restrictive size of the toilets to permit staff to assist residents there are plans to increase the size of some of the rooms. Assisted bathing facilities are strategically located throughout the home. The size of bedrooms are in some cases somewhat limited where greater assistance and equipment is required. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 Page 15 The location of the call system dictates the positioning of beds. Rooms were found to be furnished and decorated to a good standard and there was evidence of resident’s personal possessions. Resident’s names were displayed on the doors. Standard 25 was assessed at the last inspection and was fully met. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 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): 28 and 30 Staff training is adequate to ensure that staff have the knowledge and skills to meet the needs of residents. EVIDENCE: The majority of staff who possessed NVQ qualifications had achieved both levels 2 and 3. This is viewed as good practice. The induction programme for staff reflects the contents of the TOPSS programme and takes approximately 12 weeks for new staff to complete. Examination of the training file indicated that staff had undergone all mandatory and refresher courses required. The company’s manual handling trainer provides ongoing supervision of staff practices in manual handling. Other training courses have been provided for specialist subjects, which serve to enhance staff skills to meet the needs of the current client group. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 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, 36 and 38 The registered manager has a clear vision for the progress of the home that is cascaded to others. Formal staff supervisions and health and safety practices are robust in ensuring that residents are not put at unnecessary risk. EVIDENCE: The registered manager has the experience and skills to manage the home. She has undertaken training in dementia care and is currently undertaking the registered managers award training. All staff have had regular formal supervisory meetings. The majority of the trained staff have recently completed a course in this aspect and it is anticipated that they will shortly commence regular supervisions of care staff. The tool utilised for meetings was found to be satisfactory. The accident file was noted to be satisfactory, incidents were well documented and any required investigations and follow-up had been carried out. The Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 Page 18 remainder of this standard was assessed at the last inspection and was fully met. Standards 33 and 35 were assessed at the last inspection and were fully met. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 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 X 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 3 3 2 X X 3 X 3 STAFFING Standard No Score 27 X 28 4 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 3 X 3 Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14(2) Requirement Pre-admission assessment information must be comprehensive. Care plans must include life history, hobbies and preferred activities and details of the rationale for planned operative procedures. The management section of care plans on moving and handling must be completed. Falls risk assessments should not include moving and handling techniques. Care plans must be cross referenced with wound records. Care plans must include the likely triggers, usual behavioural pattern and instructions for staff in dealing with individual behavioural problems. Use of a monitoring chart assists in defining individuals trends. Timescale for action 31/03/06 2 OP7 15(1) 15/04/06 3 OP7 13(5) 15/04/06 4 5 OP7 OP7 12(1)(a) 13(4)(c) 15/04/06 15/04/06 Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 Page 21 6 OP7 12(1)(a) The registered manager must ensure that the practice of utilising a generic care plan in respect of death and dying ceases; these must be collated according to individuals needs. 15/05/06 7 OP7 15(1) The registered manager must review 31/05/06 and provide care staff with training regarding meaningful records made in care plans. The homes programme of activities must indicate how these are appropriate for individual residents especially for those suffering from dementia. The homes menu must show variety in choices and detail of the meal provided. 30/04/06 8 OP12 16(2)(n) 9 OP15 16(2)(i) 15/05/06 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 OP24 Good Practice Recommendations It is recommended that risk assessments should be carried only for those residents requiring bed rails or wheelchairs. The home is recommended to pay particular attention to the spatial requirements to meet the needs of those residents identified as high dependency. Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 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 Hurstway, The DS0000024850.V284124.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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