Inspection on 20/09/06 for The Hurstway

This inspection was carried out on 20th September 2006.

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

The Hurstway 13/07/09

The Hurstway 19/07/07

The Hurstway 16/02/06

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 Jane Walton Key Unannounced Inspection 20th September 2006 09:30 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.V313125.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. Hurstway, The DS0000024850.V313125.R01.S.doc Version 5.2 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 enquirieshurstwaycarehome@fsmail.net 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.V313125.R01.S.doc Version 5.2 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. 1st September 2006 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.V313125.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key Inspection took place over 1day in September 2006. This was the first inspection for the Inspection year 2006/07. There were 58 residents in the home and the inspector was able to speak to 6 of them. The manager was present throughout the inspection process. During the inspection process the inspector sampled residents files and case tracking was undertaken in respect of a small number of residents, in addition to inspection of other documentation relating to the management of the home. Discussion took place with 6 members of staff. What the service does well: What has improved since the last inspection? Following the last inspection the registered manager has taken action in most areas that were required. Some areas are still ongoing. Specific training for Hurstway, The DS0000024850.V313125.R01.S.doc Version 5.2 Page 6 staff in tissue viability and the legal and ethical issues surrounding this are being addressed. Efforts to improve the menu choices for residents are being addressed. All new residents have a comprehensive pre admission assessment carried out. Extensive works are underway to improve the communal facilities for the residents, including the provision of more conservatories, and improved laundry facilities. 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.V313125.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 Hurstway, The DS0000024850.V313125.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, 2,3, Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. All the practices and procedures surrounding the admission of new residents were adequate and appropriate to ensure that the home is able to fully meet their needs. Prospective residents are provided with sufficient information to enable them to make an informed choice about living in the home. EVIDENCE: There is a comprehensive statement of purpose and service users guide available for prospective residents, who are encouraged to visit the home if possible, together with their relatives. All prospective residents are assessed prior to being accepted for admission to the home. Evidence was seen in residents files of completed comprehensive pre admission assessments. Hurstway, The DS0000024850.V313125.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 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Care planning systems need to be developed further, and audit findings acted upon, to ensure all residents needs are met. The systems for medicine management require improvement in order to ensure residents medication needs and safety are not compromised. EVIDENCE: Staff had drawn up care plans for all residents and a sample were examined. Following a complaint investigation by the CSCI, a thorough audit of all care plans has been commenced, and approximately 70 have been completed. The manager has taken steps to ensure that the quality of the plans is improved, and that the documentation, with particular regard to tissue viability and the care of wounds is appropriate. It was noted that there was no method of recording the healing progress of a wound, either by a tracing or serial photographs. The manager stated that there were plans to implement a system very shortly. The care plans evidenced regular input from a range of health professionals to ensure residents health needs are met. Risk assessments are carried out, however one resident who was described as having a poor appetite did not Hurstway, The DS0000024850.V313125.R01.S.doc Version 5.2 Page 10 have a nutritional risk assessment in the file. It was stated that a referral had been made to the dietician. Where residents had been assessed as requiring hoisting, the care plan gave explicit instructions as to the number of care staff required and the size of sling that should be used, to ensure the safety of the resident. There was one care plan that stated a resident required pressure relieving equipment, however, it did not specify what the equipment should be. A regular audit of accidents and falls is carried out, and recorded. Intervention and prevention methods are discussed and implemented. It is recommended that residents who have many falls are referred to a falls clinic. All residents are registered with a local G.P. practice and doctors undertake regular visits to the home if required. Staff liaise with health professionals from the multidisciplinary team as required. An audit of the medication management in the home was carried out. There was a dedicated drugs fridge, for which the minimum/maximum temperatures are recorded daily, and were within parameters. The Controlled Drugs (CD) cupboard meets requirements. The home is supplied by a local pharmacy and utilises a Monitored Dosage System (MDS) as well as medicines boxed or in bottles. The audit was undertaken on the ground floor only. The medicine trolley was secured to the wall. The medicine management was found to be adequate, although there were discrepancies in tablet counts for 2 of the 5 Medicine Administration Record (MAR) charts examined, and there were gaps on one of the MAR charts, where signatures had been omitted. One of the residents whose chart was examined was receiving their medicines in liquid form via a PEG, apart from one tablet which was being crushed. Evidence was seen that this had been discussed with the GP and the pharmacist and a record kept of the efficacy of this. Residents are accorded privacy and their dignity upheld. All bedrooms have locks to doors and lockable facilities. All bedrooms are singles, and staff were observed to knock before entering a residents’ bedroom. Hurstway, The DS0000024850.V313125.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, 13, 14, 15 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Residents are supported to maintain social contacts. Improvements are needed to ensure that all residents have their recreational needs met. The mealtimes meet the needs of residents, but the selection of food available requires further improvement to ensure the promotion of the residents’ health and well-being. EVIDENCE: There is a dedicated activities organiser employed in the home, who appeared to have a very good relationship with residents. Since the last inspection steps have been taken to begin compiling and recording individual residents’ preferences regarding activities. Input is also requested from relatives, where a resident is unable to fully contribute. There are a large number of residents currently in the home who have a dementia, although secondary to their medical needs. It was recommended that the activities organiser attend a training course specifically to explore the kinds of activities to engage these residents in. Fortnightly flower arranging is undertaken by any residents who wish to join in. One resident said that she had enjoyed a game of bingo the day before, and that staff helped out those who couldn’t hold a pen, or had other difficulties. It was also confirmed that entertainers came to the home, and various fund Hurstway, The DS0000024850.V313125.R01.S.doc Version 5.2 Page 12 raising activities had taken place during the year, and residents were involved to the best of their abilities. The Heart of England Care provides a budget for the provision of activities for residents. The home operates flexible visiting times, and visitors are always welcome. A resident spoken to said that she was “Happy in the home. They look after me well, I like to go to bed about 8.30 as I always get up early, I always have done.” Another resident stated that she didn’t go to bed until about 10.30pm as she liked to stay up and watch television. The inspector joined the residents in Jasmine dining area for lunch and sat with 3 residents. The tables were laid with linen cloths, mats, coasters, cutlery, serviettes and condiments. Glasses were available for water or squash. Efforts have been made since the last inspection to improve the choices of food available, and a new menu produced. Each day offers a choice of 2 main dishes, together with a selection of omelettes, jacket potatoes and salad. One resident said that they would like to see a better selection of fresh salad vegetables. Another said that at times the food was “a bit bland, and needed more seasoning” The cook is currently in the process of talking to each resident individually to ascertain exactly what kinds of food they would like to see on the menu. The meal on the day of the inspection offered a choice of boiled gammon, parsley sauce, potatoes, carrots and green beans, or homemade fish pie with vegetables. Jacket potatoes and various salads were also available. This was followed by homemade trifle and cream. Staff were seen to offer assistance when required by a resident, and no one was rushed to finish their meal. There are plans to undertake building work to enlarge the dining areas for the first floor Jasmine and Primrose units. Hurstway, The DS0000024850.V313125.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 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The home has procedures for complaints and adult protection that protect residents. EVIDENCE: Examination of the complaints file indicated that the home receives relatively few complaints and those received had been investigated and resultant action taken as necessary. A formal complaint had been received by the CSCI which was investigated and appropriate measures taken and guidance given. The requirements made were followed up at this inspection and were found to have been implemented. A letter of concern was also received by the Commission and these were also followed up at this inspection, and discussed with the manager. Hurstway, The DS0000024850.V313125.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, &26 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Residents are provided with warm, comfortable and well maintained accommodation. Bedrooms although restrictive in size are furnished and decorated to a good standard. EVIDENCE: A full tour of the premises was not undertaken at this inspection as there are building works in progress. It was noted that all suitable steps have been taken to ensure on going safety throughout the works and that residents are disrupted as little as possible. Good communication between the staff in the home and the builders was evidenced, and they were aware of the importance of minimising upset for the residents. The works will ultimately provide much larger communal areas together with improved laundry facilities. A programme of redecoration will follow the completion of the building work. At the time of the inspection the areas of the home seen were clean and smelled fresh. Hurstway, The DS0000024850.V313125.R01.S.doc Version 5.2 Page 15 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, 28, 29 & 30 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The home has safe recruitment and selection procedures and this protects residents. Staff training is provided to ensure that staff have the knowledge and skills to meet the needs of residents. EVIDENCE: On the day of the inspection there were adequate numbers of staff on duty to meet the needs of the residents. Shortfalls in permanent staffing numbers are made up with agency staff. However, efforts are made to ensure that the same agency staff are used for consistency. Evidence was seen that all agency staff, when new to the home, undergo an induction to the home prior to starting their shift. The manager is currently in the process of recruiting to fill vacant posts. The manager employs a very robust recruitment procedure and evidence was seen to support this. The numbers of staff employed who have an NVQ level 2 or 3 qualification is high and exceeds the required standard. This is commended, and is seen as good practice. The Heart of England Trust employs a full time dedicated training officer. A discussion took place during which her records of staff training undertaken and booked, was examined. These were seen to be very comprehensive. Staff were seen to be up to date with all mandatory training and had also undertaken a range of complementary training in order to enhance the care offered to residents. Discussions with staff confirmed the training they had completed. All Hurstway, The DS0000024850.V313125.R01.S.doc Version 5.2 Page 16 new staff undertake a comprehensive induction course and a training matrix is maintained to ensure that training is updated when required. Following a complaint received by the Commission, training is being provided to address the management of wounds and Tissue Viability. This will include pressure sore prevention and treatment, accountability, documentation and complex care. This is to be followed by training on the legal and ethical issues surrounding tissue viability management in the home. Heart of England Care is commended on it’s commitment to provide a wide range of training for the staff of it’s homes. Hurstway, The DS0000024850.V313125.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, 36 &38 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The registered manager has a clear vision for the progress of the home that is cascaded to others. The arrangements for assisting with residents’ finances, records for the maintenance and inspection of services were good and this protects residents. The lack of formal supervision to staff could potentially put residents at 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. There is a formal Quality Assurance programme operating in the home, that follows the National Minimum Standards as a guide. The audits are carried out each month for selected standards and an annual report is produced to reflect the findings and a plan of improvements that are needed. A current survey is Hurstway, The DS0000024850.V313125.R01.S.doc Version 5.2 Page 18 being carried out with residents regarding the food quality and menu choices. A consumer survey was also carried out in June 2006, the results of which were evidenced. The administrator for the home is responsible for the management of residents’ personal expenditure. Records were audited and found to be accurate. The system appeared to be very robust. A regular monthly audit is also carried out by a Heart of England financial officer. Staff have had some formal supervision, but not on a regular basis, and the manager is aware that this issue needs to be addressed. Maintenance records for health and safety checks were examined and all were up to date. All fire alarm tests, equipment checks and maintenance, training and drills were up to date. The safety officer had just completed training all staff, day and night, in the use of the “Evac” chair. Hurstway, The DS0000024850.V313125.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 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 3 Hurstway, The DS0000024850.V313125.R01.S.doc Version 5.2 Page 20 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 2 Standard OP7 OP7 Regulation 15(1) 13(4)(c) Requirement Care plans must include life history, hobbies and preferred activities. 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. 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. This requirement was not inspected so is carried forward. The registered manager must ensure that all staff who administer medicines sign the MAR chart as they are given. The homes programme of activities must indicate how these are appropriate for individual residents especially for those suffering from dementia. Timescale for action 20/10/06 20/10/06 3 OP7 12(1)(a) 20/10/06 4 OP9 13(2) 27/09/06 5 OP12 16(2)(n) 30/10/06 Hurstway, The DS0000024850.V313125.R01.S.doc Version 5.2 Page 21 6 OP15 16(2)(i) 7 OP36 18(2) The registered manager must ensure that the audit of residents ’preferences regarding menu items is implemented as soon as possible. The registered manager must ensure that all staff have regular documented supervision at least 6 times per year. 31/10/06 31/10/06 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 OP12 Good Practice Recommendations It is recommended that a system for monitoring the healing progress of wounds is introduced. It is recommended that the activities organiser be provided with training to improve the activities available specifically for residents who have a dementia. Hurstway, The DS0000024850.V313125.R01.S.doc Version 5.2 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.V313125.R01.S.doc Version 5.2 Page 23 - 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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