Care Home: Birchdale

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What the care home does well The manager undertakes a full care needs assessment for prospective residents prior to any decision being made about admission. Some people have respite care before making a decision about permanency. Care plans are in the process of being re-written and those that have been completed are a good record of the person’s strengths and needs and how they should be assisted by staff. Care plans are supported by thorough risk assessments that record a person’s level of safety and any actions needed to reduce identified risks. People are supported to go out into the local community and to take part in activities within the home. Meal provision at the home is good – there is a choice of meal at each mealtime and people are encouraged to eat and drink when this is an identified need. People tell us that they know who to speak to if they are unhappy or if they wish to make a formal complaint. There are sufficient staff on duty to meet the assessed needs of the people living at the home. NVQ achievement at the home is high and this results in a knowledgeable staff group. Money held in safekeeping for people living at the home is held securely. What has improved since the last inspection? The manager has the information needed to undertake a risk assessment for the use of bed rails should a resident need this provision. There is now a maintenance programme in place. Some areas of the home have been redecorated and the laundry area is in the process of being upgraded – a hand wash basin has been ordered so that staff can wash their hands after handling soiled laundry. Birchdale DS0000062588.V378323.R01.S.doc Version 5.2 People are now consulted about the quality of the service offered by the home and are able to affect the way in which the home is operated. All staff now undertake induction training when they first start work at the home, although records of this training were not available on the day of the site visit. The fire alarm system is now serviced on a regular basis. What the care home could do better: Not all care plans include a photograph of the person concerned. A photograph would assist new staff with identification and help the emergency services should someone go missing from the home. Care plans need to include more information about the support people need from staff to make them more personalised and so that people get the care they have requested. Temazepam must be stored as a controlled drug – this requirement was actioned on the day of the site visit to the home. Medication administration records should include a photograph of the person concerned to assist staff with identification. A menu should be displayed so that people living at the home can access this information independently, and to inform others about the meals on offer at the home. Not all staff have had training on safeguarding adults from abuse. When this has been actioned, refresher training must be arranged on a regular basis to ensure that people are fully protected from the risk of harm. Information about advocacy services should be displayed in the home so that people are able to access this information independently. The complaints procedure should be displayed within the home so that people living at the home, relatives and others have easy access to this information and so that the manager is confident that everyone knows what to do should they have a concern or a complaint.BirchdaleDS0000062588.V378323.R01.S.docVersion 5.2Details of a person’s induction training should be retained at the home, including the start and end dates. If people start work at the home prior to their CRB check being received, they must work under supervision until it arrives and these supervision arrangements must be recorded. In-house weekly fire tests should take place consistently to be effective, and fire drills must take place every six months. People will not be fully protected from harm unless this is actioned. Key inspection report CARE HOMES FOR OLDER PEOPLE Birchdale 6 Tennyson Avenue Bridlington East Yorkshire YO15 2ES Lead Inspector Diane Wilkinson Key Unannounced Inspection 4th November 2009 10:30 DS0000062588.V378323.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Birchdale DS0000062588.V378323.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Birchdale DS0000062588.V378323.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchdale Address 6 Tennyson Avenue Bridlington East Yorkshire YO15 2ES 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) 01262 676275 01262 674908 birchdale@pcslimited.net Pennine Care Services Ltd. Michelle Langley – not yet registered Care Home 25 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (25) of places Birchdale DS0000062588.V378323.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places 25 2. Dementia - Code DE, maximum number of places 25 The maximum number of service users who can be accommodated is: 25 10th November 2008 Date of last inspection Brief Description of the Service: Birchdale is a privately owned care home that is registered to provide care and accommodation for a maximum of 25 older people, including those with dementia related conditions. It is a period property that is located in the centre of Bridlington, in the East Riding of Yorkshire. The home is in close proximity to local amenities including transport, shops, health care and leisure facilities. Private accommodation is provided over three floors in nineteen single rooms and three shared rooms. Some bedrooms have en-suite facilities, and some of these include a shower. The first and second floors of the home are accessed via a passenger lift. Communal accommodation is provided in two lounges, a dining room and a conservatory. There is a small courtyard style garden at the rear of the property. Information about the home is provided in a statement of purpose, a service user’s guide and a brochure; these inform service users and others about the scope and nature of the care and facilities on offer. Birchdale DS0000062588.V378323.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for the service is 1 Star. This means the people who use this service experience adequate quality outcomes. This inspection report is based on information received by the Care Quality Commission (CQC) since the last Key Inspection of the home on the 10th November 2008, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 10.30 am and ended at 4.45 pm. On the day of the site visit the inspector spoke on a one to one basis with one person living at the home, a member of staff and the manager. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The manager submitted information about the service prior to the site visit by completing and returning an Annual Quality Assurance Assessment (AQAA) form. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. As part of the inspection process we sent survey forms to some of the people living at the home, staff and health/social care professionals; six were returned by people living at the home, one was returned by a staff member and one was returned by a social care professional. Responses in surveys and comments from discussions with people on the day of the site visit were mainly positive, for example, ‘there is none cleaner than Birchdale’, ‘rooms have been redecorated and refurbished’ and ‘they have improved considerably under new management’. Other anonymised comments are included throughout the report. The manager told us on the day of the site visit that the current fee for residential care is from £362.04 to £410.20 per week. At the end of this site visit, feedback was given to the manager on our findings, including requirements and recommendations that would be made in the key inspection report. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Birchdale DS0000062588.V378323.R01.S.doc Version 5.2 Page 6 What the service does well: The manager undertakes a full care needs assessment for prospective residents prior to any decision being made about admission. Some people have respite care before making a decision about permanency. Care plans are in the process of being re-written and those that have been completed are a good record of the person’s strengths and needs and how they should be assisted by staff. Care plans are supported by thorough risk assessments that record a person’s level of safety and any actions needed to reduce identified risks. People are supported to go out into the local community and to take part in activities within the home. Meal provision at the home is good – there is a choice of meal at each mealtime and people are encouraged to eat and drink when this is an identified need. People tell us that they know who to speak to if they are unhappy or if they wish to make a formal complaint. There are sufficient staff on duty to meet the assessed needs of the people living at the home. NVQ achievement at the home is high and this results in a knowledgeable staff group. Money held in safekeeping for people living at the home is held securely. What has improved since the last inspection? The manager has the information needed to undertake a risk assessment for the use of bed rails should a resident need this provision. There is now a maintenance programme in place. Some areas of the home have been redecorated and the laundry area is in the process of being upgraded – a hand wash basin has been ordered so that staff can wash their hands after handling soiled laundry. Birchdale DS0000062588.V378323.R01.S.doc Version 5.2 Page 7 People are now consulted about the quality of the service offered by the home and are able to affect the way in which the home is operated. All staff now undertake induction training when they first start work at the home, although records of this training were not available on the day of the site visit. The fire alarm system is now serviced on a regular basis. What they could do better: Not all care plans include a photograph of the person concerned. A photograph would assist new staff with identification and help the emergency services should someone go missing from the home. Care plans need to include more information about the support people need from staff to make them more personalised and so that people get the care they have requested. Temazepam must be stored as a controlled drug – this requirement was actioned on the day of the site visit to the home. Medication administration records should include a photograph of the person concerned to assist staff with identification. A menu should be displayed so that people living at the home can access this information independently, and to inform others about the meals on offer at the home. Not all staff have had training on safeguarding adults from abuse. When this has been actioned, refresher training must be arranged on a regular basis to ensure that people are fully protected from the risk of harm. Information about advocacy services should be displayed in the home so that people are able to access this information independently. The complaints procedure should be displayed within the home so that people living at the home, relatives and others have easy access to this information and so that the manager is confident that everyone knows what to do should they have a concern or a complaint. Birchdale DS0000062588.V378323.R01.S.doc Version 5.2 Page 8 Details of a person’s induction training should be retained at the home, including the start and end dates. If people start work at the home prior to their CRB check being received, they must work under supervision until it arrives and these supervision arrangements must be recorded. In-house weekly fire tests should take place consistently to be effective, and fire drills must take place every six months. People will not be fully protected from harm unless this is actioned. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 9 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 Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not assessed on this occasion as there is no intermediate care provision at the home. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have a full care needs assessment prior to a decision being made about their admission to the home. EVIDENCE: We examined the care records for someone who has recently moved into the home. The records included a care needs assessment that had been completed by the manager – this contained information about medication, Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 11 medical history, mental health, diet and weight, dental and foot care, personal care and mobility/dexterity. In addition to the assessment undertaken by the home, an assessment had been obtained from the local authority; this had been written especially in preparation for the person’s admission to Birchdale. This information, along with information gathered by the home, had been used to develop an individual plan of care for the person concerned. We noted that some people have respite care at the home before they make a decision about permanency. When this is the case, there is a clear record of the date a person commenced their respite stay at the home and when the decision was made that they would live at the home permanently. The manager told us that she had an appointment to visit someone the following week to start the assessment process – this was someone who wished to transfer to Birchdale from another care home. She told us that, following completion of the care needs assessment, they would make a decision as to whether the person’s individual care needs could be met by the home. Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive an individualised package of care, including the administration of medication, that ensures their social and health care needs are met and that their privacy and dignity is respected. EVIDENCE: We examined the care records for three people who live at the home. They all included a personal details form that records the person’s next of kin, GP, medical details, the place that they were admitted from, key worker details and any allergies that the person may have. There are details of other people that have involvement with the person, such as solicitors and care managers. Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 13 Individual plans of care have been developed for each person living at the home. These are in the process of being updated by the new manager who told us in the AQAA form that the new care plans are ‘more user friendly’. We noted that some care records do not yet include a photograph of the person concerned. A photograph is needed to assist new staff with identification and to help the emergency services should someone go missing from the home. We noted that care plans include information that informs staff about how the person should be supported. We advised the manager that some of these details should be expanded upon. For example, when a care plan records that the person needs assistance with bathing, this should include the exact details of the support required, such as assistance in and out of the bath, the need to be accompanied, the ability to wash and dry themselves etc. Daily records are a thorough account of the care provided to the person concerned on that particular day, including how they spent their day, their food intake, any activities undertaken and any other information such as, ‘had supper in bed’ and ‘attended residents meeting’. Key workers complete monthly reports and these include information about activities undertaken, physical and emotional health, visits from family, friends and others and contact with health and social care professionals. They also record the time spent by key workers with the individual concerned. All care plans record the date that the plan was agreed and the date that it is due for review i.e. one year ahead. People have a formal review of their care plan that is arranged by the local authority Social Services Department on an annual basis, but we noted that care plans are reviewed and updated at any time that it is deemed to be necessary. Care plans are accompanied by detailed risk assessments. Areas covered for everyone are eating, walking, outings, moving and handling and bathing. In addition to this, there are risk assessments in place for the specific needs of the person concerned, such as medication and challenging behaviour. There are also risk assessments in place for nutrition when this has been identified as an area of concern. The manager was advised to complete nutritional risk assessments and pressure care risk assessments for everyone living at the home, even if this is currently not an area of concern – this evidences that the risk has been considered. Risk assessments record details of the hazard identified, how this can be controlled, the degree of risk, agreed corrective action, the person responsible and the review date. Everyone has a risk assessment undertaken regarding their bedroom accommodation and the use of the bathroom. This includes the Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 14 risk of falls, the need for mobility equipment and any risks associated with the room contents. We discussed the provision of bed rails with the manager. She told us that none of the people living at the home currently need a bed rail to be fitted, but she showed us the bed rail risk assessment provided by the Medicines and Healthcare products Regulatory Agency (MHRA) that was ready for use when needed. We saw evidence in care records that people are weighed on a monthly basis as part of nutritional screening. We also saw evidence of optical and hearing examinations. The manager told us that most people go out with staff at some time during the week so that they get exercise and fresh air; some people go out for a walk daily. All of the people who returned a survey told us that they receive the medical care they need and that they get the care and support they need from staff. We observed the administration of medication by a senior carer on duty at lunchtime - we noted that they wore disposable gloves to reduce the risk of cross infection. People already had a cold drink at the table so that they could take their medication. The carer only signed the medication administration record (MAR) sheets when the person had been seen to take their medication and we noted that people were asked discreetly if they would like their ‘as required’ medication. The book used to hold MAR sheets included a list of staff names and sample signatures; these were the names of staff who had undertaken appropriate training on the administration of medication. Sample signatures allow the records to be monitored to ensure that only staff who are trained in the administration of medication are carrying out this task. We noted that there were no gaps in recording on MAR sheets, that staff record the amount of medication received from the pharmacist each month and that the correct codes are used to record when medication is not given. We noted that there were no photographs attached to MAR sheets – a photograph assists new staff with identification and reduces the risk of medication being given to the wrong person. We noted that Temazepam was not being stored as a controlled drug. The manager and senior carer told us that the pharmacist had told them that there was no need to do so. However, they had been getting two staff to sign medication administration records, as they felt that this was good practice. We advised them that Temazepam must be stored as a controlled drug (this was possible, as the pharmacist had supplied the drug in a separate blister pack); they actioned this on the day of the site visit. They decided that they would also record the administration of this drug in the controlled drugs register; we Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 15 advised them that there was no legal requirement to do this but that it was considered to be good practice. One medicine is given to a service user by mixing it in with food or drink. Staff have been advised to do this by the person’s GP, as they have refused to take the medication but the GP has said that it is needed to maintain their health. The person concerned lacks capacity – we advised the manager to discuss this at the next review so that the decision making can be agreed by all parties concerned and to ensure that it is in the person’s best interests. The manager told us that none of the current service users are prescribed Insulin and that any other medication that requires storage at a low temperature would be stored in the kitchen fridge in a labelled, sealed container. The amount of medication that needs to be stored at a low temperature is currently negligible and does not warrant the purchasing of a medication fridge. The care professional who returned a survey told us that staff respect people’s privacy and dignity, and we observed this on the day of the site visit. Staff use a person’s preferred name and people wear their own clothes at all times. Currently, all people living at the home occupy a single room so they are able to see health care professionals and others in their own room. People told us that staff provide assistance with personal care in a sensitive manner. Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to live their chosen lifestyle and to maintain their independence. Meal provision at the home is good and people are able to make suggestions about changes to the menu. EVIDENCE: People’s care records include information about their previous lifestyle, their family and friends and their hobbies and interests. Each person has an individual record of the activities that they take part in and these evidence that people regularly take part in activities. Activities include watching TV, reading, listening to music, going out to the shops with staff, going out for a walk (one person goes into the town shopping every day) and Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 17 longer trips out – a recent trip was a visit to a garden centre. One person’s records included details about their birthday celebrations – a buffet tea was held at the home and the person received numerous gifts. They told us how much they had enjoyed their day. On the day of the site visit a clothing party was held and we saw that people were helped to choose clothes and try them on, either independently or assisted by staff. Daily diary sheets record any visits out of the home, any visitors seen and any activities that the person takes part in, and this information is summarised each month by key workers. We observed that routines at the home are flexible – people can decide where to spend their day, where to take their meals and whether or not to take part in activities. People told us that they can get up and go to bed at a time chosen by them. Discussion on the day of the site visit and entries in care records evidence that people are supported to keep in touch with family and friends. People are able to bring some of their possessions into the home so that they can personalise their bedrooms to make them feel more homely. The manager told us about peoples’ involvement with solicitors and the benefits agency regarding their financial affairs and we saw some of this information recorded in care plans. There is currently no information displayed in the home about advocacy services. Displaying this information would enable people to access these services independently and promote their privacy. We observed the serving of lunch and noted that there were two choices of meal at lunchtime plus a vegetarian option. The manager told us that people are asked each morning what they would like for lunch, and again in the afternoon about the choices at tea time. On the day of the site visit we saw that one person told staff that they did not like the dessert provided that day they were offered ice cream instead. We observed that people are discreetly encouraged to eat and drink by staff when they are reluctant to do so. The manager told us that two members of staff have undertaken training on malnutrition and assistance with eating. There is a three week menu in operation and we saw in the minutes of the residents meeting that people had been asked about the menus and had made suggestions about meals they would like to see included. When asked if they liked the meals at the home, five people responded ‘always’ and one responded ‘sometimes’. One person added, ‘especially at breakfast and teatimes but lunch is not always what I would like’. Another person told us Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 18 that the Sunday lunches are always good. The manager told us that she had received some adverse comments about meals in their surveys but that there is now a new cook in post. We noted that there is no menu on display – the manager intends to purchase a white board so that they can display the daily menu, any activities planned for the day and any forthcoming events. This would encourage people to check the board themselves and be more independent. Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People tell us that they know who to speak to if they are unhappy or wish to make a complaint. Some staff have had training on safeguarding adults from abuse but all staff need to undertake this training to fully protect people living at the home from the risk of harm. EVIDENCE: All of the people living at the home who returned a survey told us that they know who to speak to if they are not happy and that they know how to make a formal complaint. Staff told us that they know what action to take if anyone has any concerns about the home. In addition to this, the care professional who returned a survey told us that the home usually responds appropriately if anyone raises any concerns about the home. We checked the complaints log and noted that there had not been any complaints made to the home during the last year. However, there is a policy Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 20 in place and there is appropriate documentation ready for use should a complaint be received. There was no information on display in the home on the day of the site visit about their complaints procedure, although the information is included in the home’s Service User’s guide. This information should be displayed so that the manager can be certain that everyone, including visitors to the home, is aware of the procedure. The manager told us in the AQAA form that staff and people living at the home are aware of the procedure on safeguarding adults from abuse. We saw evidence in staff records that staff are given their own copy of the whistle blowing policy. Two members of care staff have attended training on this topic and the manager and a senior carer are booked on Manager’s awareness training in November 2009. Most staff have undertaken the NVQ Level 2 in Care award and have looked at the topic of abuse as part of this training. However, staff should have specific training on this topic to ensure that they know how to identify poor practice. The manager told us that all staff are booked on a course that is due to be held shortly at Sewerby. The manager told us that she has made contact with the East Riding of Yorkshire Council safeguarding adult’s team when she has needed advice. Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean, safe and well-maintained home although their safety would be increased if the outbuilding for storing cleaning materials was locked at all times. EVIDENCE: The manager told us in the AQAA form that surveys returned to them by people living at the home recorded that the décor of the home was ‘tired’. They now have a maintenance plan in place and, on the day of the site visit, Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 22 we noted that the handyman has started a programme of redecoration. A social care professional told us in a survey, ‘the rooms have been re-decorated and refurbished’. The manager told us that a senior manager of the organisation visits the home unannounced on a monthly basis to undertake visits under Regulation 26 of the Care Homes Regulations 2001. Any maintenance issues identified are recorded in a plan of action and then in the maintenance repair plan. The manager also told us that five new fire doors are in the process of being fitted, as recommended by the Fire Officer. We also noted that the requirements and recommendations from the last key inspection are displayed on the office wall and items have been ‘ticked off’ as they have been actioned. There is a conservatory at the rear of the premises overlooking the garden. This is used very little during the colder months although the garden is equipped with bird feeders etc. to encourage people to use it during the warmer months. However, staff told us that people do go out for a walk most days so they are accessing sunlight and fresh air. We toured the premises and noted that bedrooms contained the items required so that they could be occupied by new service users and that the home was maintained in a safe, clean and hygienic condition. There were no unpleasant odours in the home apart from in one bedroom; staff are aware of this problem and appropriate action is being taken to alleviate the problem. The manager told us in the AQAA form that six staff have done training on infection control and we observed good practice by staff on the day of the site visit. In the previous inspection report we recommended that the laundry room should be moved into the outbuilding so that staff would have the facilities to wash their hands after handling soiled laundry. The manager told us that some equipment has been removed from the laundry room and this has created space for a hand wash basin to be installed; this has been ordered. The manager said that this is the preferred option, as it would not be safe for staff to leave the main building during the night to use the laundry room. We noted that the outbuilding that contains cleaning materials and food was not locked on the day of the site visit. Although it is unlikely that people living at the home would access this area, it should be locked to promote security and good hygiene. The outbuilding should be included in the maintenance programme of the home, as it needs to be improved so that it is easy to keep clean and hygienic. Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 23 Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by sufficient numbers of staff who have received some training but refresher training is needed on various topics. There needs to be more robust recruitment practices in place to ensure that new staff are considered safe to care for the people living at the home. EVIDENCE: We examined the staff rota on the day of the site visit. This evidenced that there are always two care staff on duty plus a cook on seven days per week and a domestic assistant on three days per week. The manager works 40 hours per week, Monday to Friday, but does work over the weekend when needed. There are two senior carers employed by the home and the manager was advised that they should be identified as senior carers on the staff rota. This would clarify who is in charge when the manager is not on duty or not Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 25 available. The staff rota identifies the name of the person who is ‘on call’ outside of normal working hours. There are currently eleven people living at the home and it has been decided that one ‘waking’ member of night staff and one ‘sleep in’ member of night staff is sufficient to meet the needs of the people currently living at the home. A member of staff told us in a survey that there are ‘usually’ enough staff on duty. The manager recorded in the AQAA form that all care staff (apart from one) have achieved NVQ Level 2 in Care; this means that they have exceeded the requirement for 50 of staff to have achieved this award. In addition to this, one person has achieved NVQ Level 3 in Care and two other staff are currently working towards this award. We checked the recruitment records for two new members of staff. These included an application form where the applicants had recorded the names of two referees, their employment history and their educational achievements. For one person we noted that a Protection of Vulnerable Adults (POVA) first check and a Criminal Records Bureau (CRB) check were in place prior to them commencing work at the home. Two written references had also been obtained – one was dated and arrived before the person started to work at the home but the other was not dated. The manager assured us that the second reference did arrive prior to the person commencing work. In addition to this, a health assessment for night workers had been undertaken by the home. The records for the second person included a POVA first check but we noted that the CRB check had still not arrived. There were no recorded details of the supervision arrangements in place whilst they were waiting for their CRB check to arrive. Records in both files indicated that the staff member commenced Induction training immediately but there was no evidence of this at the home – the manager told us that their induction records had been taken by the NVQ trainer as evidence towards their NVQ award. She also said that information from Skills for Care has been used to formulate the home’s induction training package. A member of staff told us in a survey that their induction training covered everything they needed to know to do the job when they first started work. The manager was advised that induction records should remain at the home, and that the date a person commences and completes their induction training should be clearly recorded. This is to evidence that people have the knowledge they need to carry out their role and to meet the assessed needs of people living at the home. In addition to this, there should be a record of the supervision arrangements in place for new staff whilst they are waiting for Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 26 their CRB check to arrive. This is needed to ensure that people are supervised until the home has evidence that they are considered safe to work with vulnerable people. We saw individual training records for people working at the home but there is no overall training and development plan. We saw some documentation that evidences that people had attended training on infection control, fire safety (in September 2009), managing challenging behaviour, dementia care, health and safety, food hygiene, emergency first aid, palliative care, moving and handling (February 2009), safeguarding adults from abuse and malnutrition and assistance with eating. However, these details must be transferred to a training and development plan that records when the training was completed and that identifies when refresher training is needed. Current records evidence that some refresher training is overdue, including emergency first aid, health and safety and managing challenging behaviour. Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 27 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management of the home has improved but concerns remain about some health and safety aspects of the home, including fire safety, recruitment and selection and staff training. EVIDENCE: Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 28 There is a new manager in post at the home and it is evident that she is making improvements to care practices at the home; she told us that her first priority was to develop more in depth care plans. A social care professional told us, ‘I have seen an improvement in the last year. They have improved considerably under new management’. However, some areas still need further improvement, such as fire safety, recruitment and selection and staff training. The manager has completed the NVQ Level 4 Registered Manager’s award and is now working towards NVQ Level 4 in Care. She is doing Manager’s awareness training on safeguarding adults from abuse on the 19th November – this is refresher training as she previously attended the training in 2007. She attends meetings with other managers from the organisation and has had help to make improvements at the home from the manager of their ‘sister’ home in Bridlington and a senior manager from the organisation. She also uses the Care Quality Commission (CQC) website to gain advice and consults with local authority Social Services staff as necessary. The manager has completed the application form that she needs to submit to the Care Quality Commission to apply for registration as the manager. She is waiting for her CRB check to be completed via the CQC and will then submit her application. We checked the information held at the home about quality assurance. Senior staff meetings were held at the home in July and October and a full staff meeting was held in March. Residents meetings were held in May and September – 8 or 9 people attended. Minutes of these meetings evidenced that people living at the home made suggestions about activities, meal provision and helped choose new furnishings and equipment for the home. The manager told us that she recently sent out 10 surveys to people living at the home and relatives; all were returned. The information in the surveys has been collated and overall, people expressed 90 – 100 satisfaction with the service provided. This information has been recorded and will be displayed on the home’s notice board. We examined the monies held on behalf of people living at the home and associated records. Money is held securely and the financial transaction form records money in, money out and a running total. Receipts are obtained for any purchases made by service users or expenditure made on their behalf, and receipts are also given to relatives when they hand money over for safe keeping. Some people are supported to handle their own finances – one person enjoys shopping by mail order and staff support them to do this. We examined a selection of health and safety documentation held at the home. There is a current gas safety certificate in place, the electrical installation was tested in April 2008 and is valid for two years, portable appliances were tested Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 29 in October 2009, an annual fire alarm test took place in September 2009, the lift was serviced in August 2009 and hoists were checked in October 2009. We examined entries made in the accident book. These were seen to be satisfactory but we advised the manager to place one copy of the accident form with individual care plan records and to use another copy for monitoring purposes. We saw copies of associated Regulation 37 notifications that had been sent to the Care Quality Commission, although these had not been received by the inspector. In-house checks on water temperatures and room temperatures and in-house tests of the fire alarm system and emergency lighting are undertaken weekly by the handyman. However, we noted that these had not taken place for the previous two weeks when the handyman was on holiday. The manager should nominate someone else to undertake these responsibilities in the handyman’s absence to ensure the safety of people living and working at the home. A letter had been received following a recent visit to the home by a Fire Officer. They had suggested a different way of doing fire tests and that fire drills should take place every six months, preferably following the six-monthly fire training sessions. The Fire Officer is due to do a follow-up visit at the home after two months and the manager agreed to notify the CQC of the outcome of their visit. Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 30 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 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 31 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement Temazepam must be stored as a controlled drug. This is to ensure that the drug is stored securely and only administered as per the instructions from the GP and Pharmacist. 2. OP18 13 All staff must have training on safeguarding adults from abuse and regular refresher training must be arranged. This is to ensure that people living at the home are fully protected from harm. 3. OP29 19 New staff must work under 04/11/09 supervision until their Criminal Records Bureau check is received by the home. These supervision arrangements must be recorded. This is needed to ensure that people living at the home are kept safe whilst safety checks are being carried out on staff. 31/01/10 Timescale for action 04/11/09 Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 32 4. OP30 18 There must be a training and development plan in place that records up to date details of the training undertaken and the training needs of staff, as well as the need for refresher training. This is needed to ensure that all staff have the skills required to carry out their role and meet the needs of the people living at the home. 31/12/09 5. OP38 23 Fire drills must take place every six months and weekly fire tests (and other safety checks) must take place consistently to be effective. This is needed to protect the safety of the people living and working at the home, and people visiting the home. 04/11/09 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. Refer to Standard OP7 Good Practice Recommendations A photograph should be included with care plans to assist new staff with identification and to help the emergency services should someone go missing from the home. Care plans should be expanded upon to give more specific details about the assistance needed by staff to support people with personal care and other tasks. Nutritional assessments and pressure care assessments should be undertaken for everyone living at the home, not just when this has been identified as an area of concern. This identifies that risk levels have been considered. DS0000062588.V378323.R01.S.doc Version 5.3 Page 33 2. OP7 3. OP8 Birchdale 4. OP9 A photograph of each person attached to medication administration records would assist staff with identification and ensure that the person receives the medication that is prescribed for them. Information about advocacy services should be available in the home so that people can access this information independently; this also promotes privacy. A daily menu should be displayed so that people can access this information independently and so that visitors to the home can also access this information. The home’s complaints procedure should be displayed so that the manager can be confident that everyone knows what action to take should they have a concern or complaint. The storage area for food and cleaning materials should be locked at all times. This area needs to be upgraded so that it can be maintained in a clean and tidy condition. This was a recommendation at the previous inspection. The senior carers should be clearly defined on the staff rota so that people know who is in charge when the manager is not available. The date a new member of staff starts and completes their induction training should be recorded to evidence that people have the knowledge they need to carry out their role before they commence work. The manager should continue with plans to apply to the CQC for registration and should continue to work towards NVQ Level 4 in Care. 5. OP14 6. OP15 7. OP16 8. OP26 9. OP27 10. OP30 11. OP31 Birchdale DS0000062588.V378323.R01.S.doc Version 5.3 Page 34 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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