Inspection on 03/03/08 for Birchwood

This is the latest available inspection report for this service, carried out on 3rd March 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birchwood 04/01/06

Birchwood 29/06/05

Birchwood 06/10/04

Birchwood 19/05/04

Birchwood 02/02/04

Similar services:

Littledale Hall Therapeutic Community

Padgate House

Westcliffe House

Richards House

Turning Point (Hoole Road)

Stanfield House

Little Acre Care Home

Inward House Projects

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Birchwood 23 - 25 Balls Road Oxton Birkenhead Wirral CH43 5RF Lead Inspector Beate Field Key Unannounced Inspection 3rd March 2008 11:00 Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 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 Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchwood Address 23 - 25 Balls Road Oxton Birkenhead Wirral CH43 5RF 0151 653 4266 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) Arch Initiatives Christina Maria Radford Care Home 14 Category(ies) of Past or present drug dependence (14) registration, with number of places Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2006 Brief Description of the Service: Birchwood is registered to provide care for fourteen adults with past or present drug dependence. The service provides a detox programme with stays ranging between three and eight weeks. Birchwood has been recently refurbished and extended and an application has been made to the CSCI to increase the numbers of people who can use the service. Birchwood is comprised of two large adjoining three storey terraced houses and is situated in a mainly residential area next to a main road. It is close to shops, leisure facilities and within walking distance of Birkenhead town centre. All Bedrooms are single. There is a large lounge, dining room and therapy rooms on the ground floor. There is also a separate treatment room, clinic room and smoking room. Toilets and washing facilities are close to the bedrooms and there are sufficient toilets close to the communal areas. There are facilities to enable a person with a physical disability to access the service. There is a large garden with a patio area to the rear of the building. The garden is in the process of being landscaped and is currently not accessible. There is a small car park at the front of the building. At the time of this inspection, the weekly fees for the service were £950.00 per week. No additional charges are made. A service user guide and a statement of purpose, which describe the services, offered is made available to people interested in using the service and health and social care professionals. A copy of the most recent inspection report is available in the reception area. Birchwood DS0000018870.V339874.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 this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection took place over 6 hours and is based on information received about the service since the last inspection, by a questionnaire completed by the manager that gave essential information about the day-to-day running of the home and questionnaires completed by the people who use the service and health and social care staff who make referrals to the service. During the site visit time was spent in the office looking at a sample of records and policies and procedures and talking to the deputy manager and service manager. A tour of the home was undertaken. The inspector spoke with people using the service and staff and made observations of the support given by staff. What the service does well: Birchwood provides very good and detailed information to people who may want to access the detox programme it offers. It provides a highly structured and supportive environment to help people deal with their drug addiction. The assessment process ensures that the needs of the people referred can be met. Birchwood works hard to seek the views and opinions of people using the service and involving them in the day-to-day running of the service. The manager and Arch Initiatives who own Birchwood are committed to supporting staff to attend training that will help them support and care for the people who use the service in the best way. The home is well presented. It is comfortable, bright and clean, which provides a welcoming environment to people using the service. The people spoken with during the visit were very positive about the service they were receiving. Some comments made were; “The service does everything well. Staff look after us. I’m confident they will get me through.” “This is the ideal place to get support to detox and get things in place for when I leave.” The staff spoken with were confident and knowledgeable about the work being undertaken at the service. The enthusiasm and motivation of the staff creates a positive atmosphere for the people who are taking part in the detox programme at Birchwood. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 6 The service is well managed and run in the best interests of the people who use the service. 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. The summary of this inspection report can be made available in other formats on request. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who are interested in using the service are offered detailed information so that they can make sure that the service is right for them. The assessment process ensures that the needs of the people referred can be met. EVIDENCE: People who are interested in using the service provided at Birchwood and funding agencies are provided with detailed information about the service provided. This information is held in the statement of purpose, service user’s guide, resident’s handbook and contracts. The people who were spoken with at the time of the visit said that they had been given good information about the service and had been told by people who had used the service in the past, how well organised the detox programme was. They said that they agreed with the rules of the house, which are detailed in the residents’ handbook, and that although these rules place restrictions on their daily lives, they accepted them as it made them focus on their addiction issues. A sample of pre-admission assessments were seen. These identify the care and support needs of the person being referred to the service as well as risk Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 9 factors, how they may present and the action to be taken by staff to support the person referred. The service manager and deputy manager said that there has been a change to the admission process at the service. Assessments now take place by a member of staff based at the service rather than by a member of staff based at the Arch initiatives head office in Birkenhead. This is ensuring greater consistency. It was also reported that people with complex mental health needs are not being accepted. Staff have been provided with training around meeting the needs of people who may self-harm, have thoughts of suicide and depression, which better equips the staff to meet these needs when they are presented. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual health, personal and social care needs of the people who use the service are clearly recorded, and provide care staff the information they need to meet their needs. EVIDENCE: Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 11 Following admission to Birchwood each person is given an initial care plan. A senior member of staff, a key worker and the person using the service are involved in devising the care plan. The initial care plan covers the general aims of the placement, detoxification information, health issues, social issues and housing. The key worker and person using the service sign the care plans. Within the first 24 hours of admission people detoxing from drugs see the General Practitioner who works closely with the service and they agree a time frame for the detox. People detoxing from alcohol have a detox programme drawn up by medical professionals prior to their admission to the service. The care plans seen showed that risk factors such as depression and selfharming had been identified and guidance given to staff on the action they are to take to recognise and manage these risks. Care plans and risk assessments are reviewed every two weeks with the people who use the service. This is designed to acknowledge an individuals progress and to identify other issues as the individual moves closer to being discharged, such as rehabilitation, housing and counselling needs. Daily records are made of the well being of the people using the service. One to one sessions take place a minimum of twice per week with confidential notes being kept with the full knowledge and co-operation of the person using the service. The service provides a highly structured environment, which limits the ability of people to make decisions about their daily lives. People who agree to use the service, agree to these restrictions prior to their admission and understand their responsibilities to the programme. The programme includes mandatory house, group and one to one key worker sessions. The people using the service at the time of the visit said they understood the reason why the programme is structured and said it helped them to “focus on the reason for being here.” They were supportive of the rules of the service and described the house rules as “sensible” and “practical.” They said that not being able to leave the service or have visitors without permission made them feel safe. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 12 The seven people spoken with during the visit were at different stages in their treatment. All made positive comments about the service they had received so far and said they would recommend the service to other people. Some comments made were; “This is the best thing that could have happened to me,” “The service does everything well. Staff look after us. I’m confident they will get me through.” “This is the ideal place to get support to detox and get things in place for when I leave.” The views of the people who use the service are gained through key worker sessions and daily house meetings. The people who use the service said they have enough opportunities to give their views about how the service is run. Health care professionals who make referrals to the service returned 3 questionnaires. Over all, their views about the service offered were very positive. Some comments made were; “Birchwood is my first choice when purchasing detox programmes,” “Birchwood has an excellent completion rate” and this is “a good service.” Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service are provided with a structured programme of therapeutic support and complimentary activities that provide them with the support they need during their treatment. EVIDENCE: The people who use the service are admitted to Birchwood for a maximum of eight weeks to undertake a detox programme. Due to the type of service being provided restrictions are placed on their movements and actions in the house and in the community. All restrictions are shared with people prior to admission if possible or during the admission process. They are given copies of the service user guide and house rules and admissions only take place after Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 14 people have signed their contracts agreeing to take part fully in the programme and abide by the rules. These include daily house meetings, group work and one to one sessions with their key workers. The people spoken with on the day of the visit said they understood the purpose of the house rules and said the rules are there to keep them safe and assist them with their goal of detox. Restrictions are placed on visitors to the service. Visiting is not allowed during the first week of admission. People who use the service are allowed one visit per week. Visitors are permitted on Sundays at set times and the visit must be agreed with staff beforehand. Again, this is one of the rules of the house that must be agreed to by people using the service prior to admission. As well as group, house meetings and key worker sessions, complimentary therapies are provided, art therapy and life skills support, aimed at ensuring that the people who use the service are enabled to develop their life skills. The people who use the service said that there are enough activities to keep them occupied. The people who use the service can access some services based at another Arch initiative site, this includes a computer suite and an arts and crafts workshop. Community outings take place in groups and are risk assessed. Overall the people who use the service said they are happy with the service being provided. Some said they would like more outings and board games. The manager was informed of this. The people who use the service said they were happy with the quality, quantity and choice of the food and meals provided and that the cook asks them what they like to eat and will always offer an alternative. Some comments made were “Lovely food. Brilliant cook.” “The food is healthy. We get a takeaway once a week which everyone enjoys.” The menus were seen and showed that the meals provided are varied and well balanced. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service are well supported by the systems in place for managing medication and health promotion. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 16 EVIDENCE: The people who use the service have access to appropriate health care support. A General Practitioner visits the home three days per week. People using the service also have access to all primary health care facilities in the community, which include dentists, chiropody, opticians and NHS services. There has been an improvement to the support available for people who are at risk of depression, suicide and self-harm. Staff have received training in these areas and care plans now outline the action staff are to take to identify and minimise these risks. The people who use the service said that they are able to talk to their key workers or another member of staff should they have any worries or concerns whilst staying at the service. They said that they find the key worker sessions helpful. There is a policy and procedure for the safe handling and administration of medication. The procedure safeguards the wellbeing of the people using the service. A sample of medications and the corresponding documentation were seen and found to be in good order. Medication is securely held with appropriate arrangements being in place for controlled drugs. Staff have received training in the safe handling and administration of medication. The accident record was examined and was appropriately maintained. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are a number of opportunities for the people who use the service to voice their views. Staff have received the guidance they need to ensure that the people who use the service are protected from abuse. EVIDENCE: There is a detailed complaints procedure, which is included in the statement of purpose, service user guide and residents’ handbook. The complaints procedure is also gone through during the admission process to ensure understanding. The people using the service said that they knew how to make a complaint if they needed to. However, they said that any issues have been dealt with by the staff before this became necessary. They also said that the daily house meetings are a good place to raise any issues and get them resolved. These meetings are minuted and the manager is expected to respond to any issues raised as soon as possible. Since the last visit to the service there have been no complaints made to the CSCI or directly to the service. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 18 There is a comments book for people to use at the end of their stay which helps the manager to assess if the programme they are providing is meeting the needs of the people using the service. There is also a suggestions box in the reception. A representative from Wirral Advocacy Service visits Birchwood weekly. There is an adult protection procedure available and a copy of Wirral Social Services’ protection of vulnerable adults protocols. The staff spoken with demonstrated an awareness of how to ensure the people using the service are protected from abuse. Staff are provided with guidance on how to manage adult protection issues through the Drug and Alcohol National Occupational Standards training, which is provided to all staff. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Birchwood provides a safe, homely and comfortable environment for people during their stay at the service. EVIDENCE: Since the last visit to the service Birchwood has been totally refurbished. A tour around the service showed that that it is well presented, furnished to a good standard and clean. The service has also been extended providing further bedrooms, more communal space and more rooms for treatment and group work. An application has been made to the CSCI to increase the number of people who can use the service. The people using the service said that the service is nicely presented and that their bedrooms and the communal rooms are comfortable. They said they feel Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 20 relaxed at Birchwood and that they also feel safe. Some people who use the service commented that the building is too warm and that there is sometimes a smoky odour from the smoking room, which they said is not nice if you do not smoke. These issues were brought to the attention of the manager. There is an expectation that the people using the service will be involved in some domestic duties as part of their detox programme such as keeping their bedrooms clean and helping with the dishes after meals. The service manager reported that domestic staff are currently being recruited to maintain the bathrooms and the communal areas. This is currently the responsibility of the support staff. Locks are in place on bathroom doors but are not on bedroom doors. This is due to the risk to the well being of people using the service being greater than the benefits. The manager was advised to ensure that this is made clear in the service user guide and statement of purpose so that people are fully aware of this before using the service. The steps taken to ensure the privacy and dignity of the people who use the service and their safety needs also to be clearly stated. The house rules state that people who use the service are not allowed in bedrooms other than their own. Records show that the gas and electrical wiring are safe. The fire alarm and emergency lighting are tested by staff at the home to make sure they are working properly. Records of fire drills and fire safety training provided to staff could not be located during the visit. Evidence that this instruction is provided to staff needs to be available at the service. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service benefit from having appropriately trained staff who are clear about their roles and responsibilities. EVIDENCE: The staffing levels are sufficient. At the time of the visit there were 10 people using the service. The rota for the week of the visit and the previous week were seen and staff spoken with about the staffing levels. Staff reported that there are enough staff to meet the needs of the people using the service and the records supported this. A cook is now employed at the weekends, which means that the two staff on duty can concentrate on meeting the therapeutic needs of the people using the service. There are two groups of staff who provide support to the people who use the service. Substance misuse workers, who are responsible for key working and leading group work, and the support workers, who are responsible for the dayBirchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 22 to-day support of clients. Staff spoken with were clear about their roles and responsibilities. Since the last visit to the service training has been provided to staff to support them in their day-to-day work such as training around multi-agency working, motivational interviewing and specific mental health issues. The training records seen were not up to date and the manager was asked to ensure these are updated. Four staff have now completed the Drug and Alcohol National Occupational Standards (DANOS) training and the remaining staff are working towards this. Members of the staff team spoken to felt the manager and the deputy are supportive and approachable. They confirmed they have regular supervision, which, looks at their practice, work performance and allows them to identify training needs. People who were using the service at the time of the visit said that the staff treat them with dignity and respect. Some comments made were, “some of the staff have been there, they know what we are going through and this helps me through.” “Staff treat us like individuals.” “It feels like a family, the staff are part of the family, it isn’t us and them.” People who use the service said they “feel safe and supported” by the staff team. Some comments made were “The staff are good at picking up when you feel down.” “The staff are caring.” Arch Initiatives has a central staffing and recruitment section that deals with all recruitment requirements for the whole organisation including Birchwood. A sample of records were seen and in general contained the required information. No further information other than a criminal records bureau check could be located for one member of staff. This was brought to the attention of the manager to be addressed. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Birchwood is managed well by an effective management team. EVIDENCE: The manager has been in post for 2 years and has completed the Registered Managers Award. The manager’s main responsibilities are to oversee the operation of the home and to oversee the activities that are apart of the programme of treatment. The deputy manager is a registered nurse and has had relevant work experience before beginning his employment at the service. The deputy manager oversees the detox plans for the people using the service. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 24 The staff spoken with were confident and knowledgeable about the work being undertaken at the service. The enthusiasm and motivation of the staff creates a positive atmosphere for the people who are taking part in the detox programme at Birchwood. There is an open and inclusive approach at Birchwood. The people using the service have numerous opportunities to make their views known and contribute to how the service is operating. Staff meetings are also held on a regular basis. The service manager or the responsible individual visit monthly. At present they do not write a report of their findings. A written report needs to be made available as this provides evidence that the operation of the home is being overseen by the organisation that has the ultimate responsibility for it. The service manager agreed to address this. Training around safe working practices is made available to staff as part of their induction. There is a rolling programme of training opportunities provided and refresher courses are undertaken when needed. There are policies and procedures and risk assessments available that promote safe working practices. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23 Requirement The registered persons must ensure that a record is maintained of fire drills and of fire safety training provided to staff. The registered persons must ensure that the arrangements for respecting the privacy and dignity of the people using the service are fully documented in the Statement of Purpose and Service user Guide. The registered persons must demonstrate that the required information in Schedule 2 of The Care Homes Regulations 2001 has been obtained in respect of staff to ensure their suitability to work with vulnerable adults. The registered provider or their representative must prepare a monthly written report on the conduct of the care home. Timescale for action 03/03/08 2. YA24 4 03/04/08 3. YA34 19 03/03/08 4. YA39 26 03/04/08 Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 27 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 YA24 Good Practice Recommendations Fire safety training should be provided to day staff on a 6 monthly basis and to night staff on a three monthly basis. Birchwood DS0000018870.V339874.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court, Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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