Inspection on 01/11/05 for Wythall Residential Home

This inspection was carried out on 1st November 2005.

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

Wythall Residential Home 02/02/07

Wythall Residential Home 01/07/05

Wythall Residential Home 11/01/05

Wythall Residential Home 21/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Wythall Residential Home 241 Station Road Wythall Birmingham West Midlands B47 6ET Lead Inspector Y South Unannounced Inspection 1st November 2005 10:15 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 Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 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. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wythall Residential Home Address 241 Station Road Wythall Birmingham West Midlands B47 6ET 01564 823478 01564 829834 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) Wythall Residential Home Limited Mrs Linda Ann McIntyre Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22), of places Physical disability over 65 years of age (22) Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The room is registered for service users who do not have a mobility difficulty or any dementing type of illness. 1st July 2005 Date of last inspection Brief Description of the Service: Wythall Residential Home is situated on a main road in Wythall with ready access to public transport and local shops. There is parking space at the front of the home. The Home is a converted detached house, which has a purpose built extension. With the exception of one room known as the flat, all registered accommodation is on the ground floor. There are 18 single bedrooms, 9 of which have en-suites and two double rooms, 1 of which has an en-suite. Other facilities provided for service users include a large spacious lounge and dining area. The home provides personal care in a homely environment for up to 22 older people who may have physical disabilities and/or mental health needs associated with older age. The registered providers are Mr A P Barwell and Mrs S J Barwell who have a regular presence in the home. The registered manager is Mrs L McIntyre, who is experienced and qualified to manage the home. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over five hours from 10.15am until 3.15pm. The registered manager assisted the inspector. The inspector also spoke to four residents. A partial tour of the building took place and a range of documents were seen. The focus of the inspection was on the requirements and recommendations that had been made following the previous inspection, and standards concerned with health, protection and rights, staffing and quality. Prior to this inspection the manager was asked to distribute questionnaires regarding the service to residents, relatives and health care professionals. The completion of these is voluntary but proves useful in assessing the various views that are held. Four responses have been received. What the service does well: There is a lovely homely atmosphere and a strong caring staff team who have a good relationship with the people who live in the home. Residents describe the care they receive as good and the food as lovely. Relatives describe the home as providing a welcoming, caring, happy and peaceful environment and the staff as kind and helpful. Staff are friendly efficient and always cheerful. Staff are aware of residents needs. My mind is at rest. The home provides comfortable rooms that are well furnished and maintained. Activities and stimulation are provided. For example on the day of the inspection the house was still decorated for the Halloween party that had taken place on the previous evening and a bonfire was built in the garden ready for November 5th. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 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 Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 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 The home is able to meet the needs of the people who are admitted. EVIDENCE: Pre admission assessment records were inspected. They were detailed and informative; providing sufficient information on which to make a decision regarding admission and enabling an initial care plan to be drawn up. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 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): 8, 9 The health care needs of residents are being met and residents are cared for with respect and consideration. There is a risk of medication error resulting from the lack of a strong checking system for hand written records. EVIDENCE: Three recommendations were made following the last inspection and compliance was checked during this visit. It was observed that neither the member of staff making the record or the person checking its accuracy were signing handwritten administration records. It was observed that when residents self-administered their own medication their records indicated when stock was given into their care. Not all tubes of creams and ointments had been dated when opened. More consistency is needed in this area. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 Page 10 Health care records were assessed and clearly indicated that needs had been identified and appropriate action had been taken. Health care professionals and specialists had been consulted when necessary. It was recommended that full nutritional, moving and handling and pressure care assessments be undertaken as soon as possible after admission. It was observed that residents were treated with kindness and respect and residents and relatives endorsed this opinion. The manager confirmed that personal care was undertaken in private. Visitors could be received by residents in their bedrooms or in the communal lounge. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed during this inspection. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 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, 17, 18 Information was provided to guide residents and supporters who had concerns that they wished to raise. Legal rights were protected and there were policies and procedures in place to guide staff in protecting vulnerable people from abuse. EVIDENCE: The complaints procedure was available in the Service Users’ Guide placed in each bedroom. A minor amendment needed to be made to ensure people were aware that they could contact the Commission for Social Care Inspection at any time. The record indicated that no complaints had been received in the home since the previous inspection. The manager said that no one needed an advocate at the time. However information was available should the need for one arise. Everyone was registered on the electoral roll and postal votes were obtained for election times. Policies and procedures were available concerning the protection of vulnerable people and whistle blowing. Staff training was provided and support given to them to provide care for residents with challenging behaviour. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 Page 13 Staff were advised on appointment that they were not permitted to accept gifts from residents or benefit from bequests. Information also needed to be included in the staff handbook that they should not assist residents in drawing up their wills. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 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 Residents live in a well maintained house that is clean, attractively decorated and furnished. Action needs to be taken in some areas to reduce the risks of cross infection. EVIDENCE: A requirement had been made in the previous report that risk assessments for the garden should be drawn up. This requirement had been met. A partial tour of the home was undertaken. It was well maintained and the decoration and furnishings were of a good standard. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 Page 15 A programme of routine maintenance was not available but the manager maintained a record of each room and used this to identify and prioritise improvements and a maintenance book indicated that repairs were promptly addressed. The walls in the laundry needed attention, as parts could not be readily cleaned. There was no hand basin in the laundry but there was one in the staff toilet cubical and in the freezer store next door. This latter room needed a supply of liquid soap. There was a wheelchair in use that needed repair and cleaning. Personal toiletries had been left in the communal bathroom and the bath hoist seat needed cleaning. Although the house was clean and odour free the dining room carpet was obviously in need of cleaning. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 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): 27, 30 The staffing levels and skill mix enables the needs of the residents to be met. Staff awareness of health and safety matters has been raised through training. EVIDENCE: The duty roster indicated that sufficient staff were on duty to meet the needs of the residents. Vacant shifts were covered by other staff. The manager confirmed that she had the authority to increase staffing levels if the needs of residents warranted this. She praised the staff team for their skills, care and loyalty. The manager needs to include her hours on the duty roster and amend them if necessary as the week progresses. The manager said that all staff had received training in health and safety and now had a workbook to complete as evidence of their understanding before a certificate was presented. A staff training analysis and plan was not available for inspection. The manager undertook to send copies to the Commission for Social Care Inspection following the inspection. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 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, 38 A quality assurance system needs to be implemented to identify areas were the service can be developed and improved. The financial system in use protects the interests of the residents. Staff need to receive individual support and guidance as to how they can improve their care practice. The programme of system and equipment checks reduces fire safety risks but staff awareness needs to be maintained by more frequent training. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 Page 18 EVIDENCE: There was no quality assurance system in use. Participation in the ‘Investors in People’ programme was still under discussion. Residents had completed questionnaires but they were not dated and it was not clear that the responses had been analysed or actioned. There was no annual development plan for the home. A maintenance and renewal plan, training needs analyses, and residents’ questionnaire responses would help in the development of such a plan. The provider’s representative undertook visits monthly. Reports were provided to the manager but not to the Commission for Social Care Inspection as is required. The home did not manage money for residents. Purchases of such things as toiletries were made on their behalf when necessary and invoices were sent to the residents’ representatives. A requirement to provide individual supervision at least six times a year for all care staff had not been met. This requirement has been unmet for a long time. The manager said that she guided staff in a less formal manner and did not maintain records. However records are needed to ensure progress is achieved. Discussion took place as to how 1:1 sessions could be conducted covering practice and care and the development of the individual’s knowledge and skills. The fire log indicated that the fire safety checks were being carried out, the fire risk assessment for the home was up to date and fire drills and formal training sessions were undertaken. The frequency of fire safety training in house needed to be increased to every three months. Advice was given as to how formal training sessions, discussion and analysis of fire drills and ‘false alarms’ could be used to achieve the four training sessions a year recommended by the Fire Authority. Close monitoring must be maintained to ensure all staff are included. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 X X 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 1 X 3 1 X 2 Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 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 OP16 Regulation 22 Requirement Information must be available in the complaint procedure that people can contact the Commission for Social Care Inspection at any time. An address and a phone number must also be given. Timescale for action 31/12/05 2 OP26 13, 16 31/12/05 Measures must be taken to reduce the risk of cross infection. Specifically • The laundry walls must be washable • The dining room carpet must be cleaned. • Personal toiletries must be returned to their owner’s room. • The bathroom equipment must be cleaned after every use. • The wheelchair must be serviced and cleaned. • Liquid soap must be available at all communal sinks/hand basins. Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 Page 21 3 OP33 24 4 OP33 24 5 OP30 12 6 OP33 26 7 OP33 24 8 OP36 18 9 OP38 23 The results of service users’ surveys should be published and made available to interested parties. This can be done through the statement of purpose and the service users guide. Effective quality assurance and quality monitoring systems must be in place based on seeking the views of the residents to measure the success of the service. A training and development programme should be available and part of the annual development plan for the home. Copies of the reports generated by the provider’s representative in accordance with regulation 26 should be sent monthly to the Commission for Social Care Inspection. There should be an annual development plan for the home based on a systematic cycle of planning – action – review, reflecting aims and outcomes for service users. Care staff must receive formal 1:1 supervision (support and development) at least six times each year and records must be maintained. (This requirement is outstanding from previous inspections.) Staff must receive quarterly fire safety training in accordance with the guidance given by the Fire Authority. Records and a monitoring tool must be used to ensure no one is overlooked. 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 31/12/05 Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 Page 22 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 Refer to Standard OP9 OP9 OP8 Good Practice Recommendations MAR sheets that are hand written should be checked by a second person and the entries double signed. Tubes of medicinal creams, ointments and gels should be dated when opened to assist in stock control and monitoring. Full assessments of nutrition, pressure care and moving and handling needs should be undertaken as soon as possible after admission and appropriate care plans be drawn up based on the identified needs. Information should be available that staff are not permitted to assist residents in making their wills. A programme of routine maintenance and renewal of fabric and decoration should be available and part of the annual development plan for the home. 4 5 OP18 OP19 Wythall Residential Home DS0000018491.V251200.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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