Inspection on 15/03/06 for West Heath House

This inspection was carried out on 15th March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

West Heath House 09/07/07

West Heath House 04/09/06

West Heath House 07/11/05

West Heath House 23/03/05

West Heath House 18/08/04

West Heath House 19/02/04

West Heath House 03/09/03

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

CARE HOMES FOR OLDER PEOPLE West Heath House 90 Alvechurch Road West Heath Birmingham B31 3QW Lead Inspector Yvonne Reay Unannounced Inspection 15th March 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 West Heath House DS0000033605.V279964.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. West Heath House DS0000033605.V279964.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service West Heath House Address 90 Alvechurch Road West Heath Birmingham B31 3QW 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) 0121 475 3614 0121 478 0130 Birmingham City Council (S) Mrs Imelda Walley Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places West Heath House DS0000033605.V279964.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. That home is registered to accommodate 26 people over 65 years who are in need of care for reasons of old age which may include mild dementia. Registration category will be 26 (OP) That minimum staffing levels are maintained at 3 care staff throughout the waking day of 14.5 hours. That additional to above minimum staffing levels there must be two waking night care staff. All toilets must be partitioned from floor to ceiling by 30th April 2005. Date of last inspection 7th November 2005 Brief Description of the Service: West Heath House is a large purpose built two-storey building, located on the Alvechurch Road in West Heath. It is situated at the top of the road overlooking the main road with views all around the immediate area. The building is approached via a drive to the front with some off road parking. West Heath House offers accommodation to twenty-six older adults. All bedrooms are single with a wash hand basin facility, and emergency call system. Bedrooms are located on the ground and first floor, with access via a passenger lift. There are two lounges, one smoking and one non-smoking, a dining room, main kitchen and office and medical room. The laundry is situated on the first floor. Toilets and bathrooms are situated on both floors. There is an enclosed garden with a patio to the rear of the house, and open lawn areas to the front and sides. The home is opposite a church and parade of shops; a number of bus routes to the city and surrounding area are within walking distance. West Heath House DS0000033605.V279964.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over 1 day in March 2006 and the Assistant Manager was present throughout the process. Requirements from the previous inspection were assessed for compliance and some service users and staff were spoken to. Records were inspected and a partial tour of the premises was conducted. Medication management was also inspected. The Inspector was informed that the home was not currently taking admissions due to the ongoing refurbishment and redecoration programme. There were 20 residents in the home on the day of the visit. This report should be read in conjunction with the report from the most recent inspection in November 2005. What the service does well: What has improved since the last inspection? What they could do better: Staffing levels need to reflect the current levels of dependency of service users. Record keeping could be improved in a number of areas in particular: *Medication administration; *Care plans; *Records of residents weight gains/losses and any actions taken when weight loss is identified; *Staff induction records. West Heath House DS0000033605.V279964.R01.S.doc Version 5.1 Page 6 Some matters appear to be out of the control of the Registered Manager and impact on the running of the Home. 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. West Heath House DS0000033605.V279964.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 West Heath House DS0000033605.V279964.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): 3 No service user moves into the Home without having his or her needs assessed. EVIDENCE: A full assessment of need is carried out by a Social Worker prior to admission to the Home and a record is kept of this assessment. These records were seen on the day of the visit on those service users files inspected. West Heath House DS0000033605.V279964.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 Service users appear to be mostly treated with respect and the Home generally delivers a satisfactory standard of care. Service Users are not fully protected by the Home’s practices on administration of medication. The record keeping in relation to care plans requires attention to ensure current care needs are clearly detailed. EVIDENCE: From observations made and following discussions with staff it was evident that the dependency of some residents currently in the home had increased over the last 18 months. For example: *5 residents have complex moving and handling needs; *1 service user has advanced Parkinson’s disease and is very dependant on care staff for all her needs; *1 service users is doubly incontinent and another 4 service users are also incontinent; *1 service user is cared for mainly in her bed: *A high proportion of service users appear to be confused. With this level of dependency it is likely that current staffing levels are not sufficient to ensure service users needs are met in full. Feedback from staff on duty on the day of the visit confirmed this. West Heath House DS0000033605.V279964.R01.S.doc Version 5.1 Page 10 Medication is stored securely and staff that administer medication are appropriately trained to do so. Medication Administration Records were in place and there was a photograph of each service user to assist with identification. The mediation was audited for three service users and discrepancies were noted in the medication management for each individual. For example from the amount of some medication remaining and that signed for it is likely that some medication had not been administered but had actually been signed for. All of these service users had been prescribed PRN (when required) analgesia however it was clear that they rarely required this. The medication must be reviewed by the GP in these instances to avoid over prescribing and preventing waste. It was suggested that a Homely Remedy supply of medication be purchased in line with the homes own policy. Residents were sitting in the lounges following lunch and appeared comfortable and well presented. One resident stated that she was comfortable at the home and staff were ‘kind to her’. Where it was possible to converse with service users they did not appear to have any complaints. Care plans and Individual Service Statements were in place and there was information about the assessed needs of the individual. However individual files for service users were messy, disorganised and pieces of paper were falling out of the files. It was difficult to determine the current care needs and there were no easily accessible and clear instructions for care staff to follow to meet the needs of the individual. Some information had not been updated for example individual risk assessments and moving and handling risk assessments. Records were in place to show visits from Other Health Professionals for example the GP. Records of weight were inconsistent and those in place showed a significant weight loss for a number of residents. Records did not consistently demonstrate that appropriate actions had been taken to address this. An Immediate Requirement was left with the Assistant Manager for measures to be put into place to remedy this matter. West Heath House DS0000033605.V279964.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): None of these standards were inspected on this occasion. EVIDENCE: West Heath House DS0000033605.V279964.R01.S.doc Version 5.1 Page 12 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 There was evidence that complaints are mostly listened to, taken seriously and acted upon. EVIDENCE: The Home has a complaints policy, which meets this standard. A recent complaint (December 2005) received by the Home appeared to have been dealt with appropriately and the record had all the details of the complaint. However it may be better if the detail for each complaint was kept on a separate log sheet. This would then show an individual record of each complaint, any actions taken and outcomes. West Heath House DS0000033605.V279964.R01.S.doc Version 5.1 Page 13 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, 21, 23, 26 When the planned redecoration and refurbishment work has been fully completed service users will live in a pleasant and well-maintained environment with suitable toilet facilities. The Home is clean and hygienic. EVIDENCE: A programme of redecoration and refurbishment is underway following requirements from the last inspection and some areas have been completed. On the first floor: *Corridors have been repainted and new carpet has been laid; *The toilets have been partitioned and new flooring has been laid; *Many bedrooms have been repainted and overall the environment is fresher and brighter than indicated in the previous report. All three lounges in the home have been redecorated and new lights fitted. However with the amount of new lights in place it is likely this lounge will be very bright. The smoking lounge has also been redecorated. West Heath House DS0000033605.V279964.R01.S.doc Version 5.1 Page 14 The toilets on the ground floor are being refurbished and when finished will allow for wheelchair access. The Inspector was informed that the work on these toilets has been ongoing for some time and is causing disruption within the Home. It would be beneficial to service users and staff if this work were completed within the specified timescale. It was noted that at the base of a door leading from the smoking lounge to small lounge off the dining room had a protruding metal strip across the floor. This was a potential trip hazard and should be removed. On the day of the visit the Home was warm, clean and odour management was good. The Inspector was informed that there is no current plan to resite the laundry, which was a requirement from the last inspection. The Registered Manager has since informed the Inspector that this matter is ongoing and is part of discussions between Senior Management of both Health and Social Care and CSCI. Other work, which remains outstanding from the previous inspection and has not been addressed includes: *Repainting of the outside of the premises; *Redecoration of the main kitchen; *The fitting of automatic door closures on all bedroom doors. West Heath House DS0000033605.V279964.R01.S.doc Version 5.1 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, 29, 30 Service users needs are not met in full by the numbers of staff on duty. Service users are protected by the Home’s recruitment policy and practices. EVIDENCE: There are a number of staff currently on long term sick. Staff are working extra hours to cover shifts and agency staff are not employed clearly putting pressure on staff. There has been recruitment for new care staff and staff have been appointed however the required checks are still being carried out. With the levels of dependency of some service users currently in the home it is clear that staffing levels are not sufficient to ensure care needs are consistently met in full (see also standards 7-10). One staff file was examined for the newest permanent recruit to the home and the required paperwork was in place to demonstrate safe recruitment practices and a CRB check had been undertaken. The Registered Manager must ensure CRB checks are stored in line with CRB and Data Protection guidelines. The home has an Induction programme in place in conjunction with Birmingham City Council, which is recorded in a ‘Staff Development Framework’ folder. Training and supervision records are also kept in these folders. However due to staff keeping this folder with them there was no record of induction on file for inspection purposes for this new member of staff. It was suggested that a tracking record be kept in each staff members file to demonstrate ongoing/completed inductions and at what stage they are at. West Heath House DS0000033605.V279964.R01.S.doc Version 5.1 Page 16 There was evidence that staff have a three-month probationary assessment following employment and some of these records were seen. Some staff had also completed a TOPPS Induction programme however the one completed induction seen was not dated. West Heath House DS0000033605.V279964.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): 33, 35, 36, 37 Service users financial interests are safeguarded and staff appear to be appropriately supervised. Further development is required to the Home’s record keeping in some areas. EVIDENCE: The record keeping for service users personal allowance was examined and satisfactory procedures are in place to safeguard service users financial interests. Individual records are kept which are regularly audited and checked by both the Home’s staff and a Senior Team Leader for Social Care and Health. The Inspector was informed that service user meetings are held however minutes could only be located for a meeting held in January 2005.However following the inspection minutes from a meeting held in March 2006 have been provided. West Heath House DS0000033605.V279964.R01.S.doc Version 5.1 Page 18 The Inspector was also informed that feedback is sought from service users covering all aspects of life in the Home. However it was only possible to evidence feedback about the meals provided. In the absence of an administrative assistant, who is also on long term sick leave it may be a likely explanation as to why some records could not be located. It may be beneficial if the Assistant Manager(s) has some supernumery time allocated to enable the effective carrying out of any extra managerial tasks. Information supplied to the Inspector indicated that there has been a long period of instability in the Home. The recruitment of new staff has been slow and this is out of local control. There are high levels of sickness and the redecoration programme has caused some disruption in the Home. Supervision is undertaken and the supervision agreement with staff was seen. Staff keep their own supervision records and were not examined on the day of the visit. It would be useful for inspection purposes to see a schedule (matrix) of supervision planned and undertaken for staff. When formulating this plan the Registered Manager should ensure the level of supervision is appropriate to individual experience and need. West Heath House DS0000033605.V279964.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 X 3 X X N/A 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 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 3 2 X West Heath House DS0000033605.V279964.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 OP8 Regulation 17(1a)S3 m 17(2)S4(1 3) Requirement Timescale for action 29/03/06 2. OP9 3 OP7 4 OP21 5 OP33 The Registered Person must carry out a full audit of all residents weight gains/losses. Records must show that appropriate actions have been taken when weight loss has been identified. 13(2) The Registered Person must ensure that following a medication audit appropriate actions are taken to rectify any errors identified and that this is addressed with the staff member. 15(1) The Registered Person must ensure that the service users plan clearly sets out in detail the actions, which need to be taken by care staff to meet the needs of the service user. 23(1)(n) The Registered Person must ensure that the work in progress to the toilet facilities on the ground floor is completed in the timescale identified. 24(1)(a,b) The Registered Person must (3) ensure that there is demonstrable evidence that the views of service users are sought DS0000033605.V279964.R01.S.doc 29/03/06 30/04/06 30/04/06 31/05/06 West Heath House Version 5.1 Page 21 6 OP19 23(2)(d) 7 OP27 18(1)(a) 8 OP30 18(1)(c) (i) when monitoring the quality of the service provision. The Registered Person must ensure that the programme of redecoration and refurbishment both externally and internally is completed within the timescales. The Registered Person must ensure that staffing levels are sufficient at all times in order to meet the assessed needs of the service users. The Registered Person must ensure there is demonstrable evidence that all new staff have received a full induction. 31/05/06 30/04/06 31/05/06 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 3 4 Refer to Standard OP9 OP16 OP36 OP27 Good Practice Recommendations It was suggested that a Homely Remedy supply of medication be purchased in line with the homes own policy. It was suggested that each complaint be kept on a separate log sheet. This would then show an individual record of each complaint actions taken and outcomes. It would be useful for inspection purposes to see a schedule (matrix) of supervision planned and undertaken for staff. It may be beneficial if the Assistant Manager(s) had some supernumery time allocated to enable the effective carrying out of any extra managerial tasks to be undertaken. West Heath House DS0000033605.V279964.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 West Heath House DS0000033605.V279964.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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