Inspection on 26/02/08 for The Birches Nursing Home

This is the latest available inspection report for this service, carried out on 26th February 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Birches Nursing Home 19/10/05

The Birches Nursing Home 28/04/05

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE The Birches Nursing Home 239 Water Lane Totton Southampton Hampshire SO40 3GE Lead Inspector Chris Johnson Key Unannounced Inspection 26th February 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Birches Nursing Home Address 239 Water Lane Totton Southampton Hampshire SO40 3GE 023 8066 7141 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) Harcare Ltd Mrs Lesley Kay Head Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21), Physical disability (25), Terminally ill (25) of places The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2007 Brief Description of the Service: The Birches is a care home providing accommodation and nursing care for twenty-one residents. Accommodation is provided on two floors in nine single bedrooms and six shared rooms. The home has a lounge and dining area and a small garden. The top floor of the home has an office and a staff training/rest room. The Birches opened in 1991 and is privately owned by Mr Peter Harrison and Mr Paul Harrison. The home is situated in a residential area of Totton, Southampton and is close to all local amenities. The cost of living at the home ranges from £543.00 to £640 per week. Additional costs are charged for newspapers, hairdressing and chiropody. The Birches Nursing Home DS0000062660.V356960.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. The purpose of this inspection was to assess how well the home is doing in the meeting of all key National Minimum Standards and to assess what the outcomes are for people who live at his home. The findings of this report are based on a number of different sources of evidence. These included: An unannounced visit to the home, which was carried out on 26th February 2008. All regulatory activity since the last inspection was reviewed and taken into account including any notifications sent to the Commission for Social Care Inspection. The manager completed an Annual Quality Assurance Assessment (AQAA) prior to the visit. Records, policies and procedures were examined at the home and Surveys were sent to ten members of staff, five of the people who live at the home and five health professionals. At the time of writing this report we had received completed surveys from four people living at the home and four members of staff. During this visit we looked at the physical environment including, people’s bedrooms and all communal areas of the home. Staff and care records were inspected. Some members of staff were spoken with and others were observed during their day-to-day interactions with those living at the home. The inspectors spoke with other people individually. The manager was present throughout to answer questions and discuss issues. Verbal feedback was provided at the end of the inspection. What the service does well: The home makes sure that it can meet a person’s needs before offering them a place at the home. People living at this home can receive visitors as often as they please and keep in touch with their family and friends. Their visitors are made to feel welcome. People are free to make their own decisions and choices and live the lifestyle that they choose. They receive a healthy diet and have access to all medical support as necessary. The home is clean and tidy with sufficient procedures and systems in place to minimise the risk of cross infection. Staff are caring, helpful and have a good understanding of peoples’ needs. They are well trained and undergo a The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 6 thorough recruitment process and this provides people living at the home with protection. People have confidence in the management of the home and know how to address any concerns that they may have. 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. The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 and 5 People who use 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. Peoples’ needs are fully assessed prior to admission so that the individual and the home can be sure that the home is right for them and will meet the person’s needs. EVIDENCE: The information in the Annual Quality Assurance Assessment (AQAA) told us that an assessment process continues to be in place as has been found at previous inspections of the home. We found sufficient evidence to support this. Pre admission assessments and care notes were looked at for people who had moved into the home since the last inspection. These demonstrated that people had been assessed prior to admission to determine whether the home could meet their needs. The manager carries out the assessment in whichever setting is most appropriate to the person, be that their own home, hospital or The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 9 the care home. Care management assessments had been obtained where appropriate as had transfer notes from the person’s previous setting. In discussion with people living at the home and their relatives all confirmed that the manager had visited the prospective service user to assess their needs prior to admission. Everyone who returned a survey said that they had received enough information about the home before they moved in so that they could decide if it was the right place for them. People have the opportunity to visit the home before making a decision. Several people spoken with said that their relatives had done so on their behalf. One relative commented, “We walked in and on being taken around could tell it was quite right for the patient concerned”. Staff said that they considered that they had enough information about people when they moved in to be able to care for them. One staff member commented, “When a resident comes into our care at the home every member of the care staff receives a full handover on the resident including special requirements, past medical history, care needs etc”. All staff who completed a survey said that they are given up to date information about the needs of the people that they supported and cared for. We noted that the home had not recorded that people had formally agreed to share a room and in discussion with the manager it was agreed that this is something that either the person or their representative could sign to say that they were in agreement with prior to moving in. The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People who use 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. Peoples’ support needs are set out in care plans to guide and inform staff as to how to provide people with the support that they need. Medication is managed safely and people have access to healthcare support as necessary. EVIDENCE: The care plans of four people were examined during the visit to the home. Risk assessments had been completed as necessary and risk management plans were in place to address any identified risks. The care plans are written and updated by the trained staff using a standard format and the care staff said they pass on changes and information daily about each person. In discussion with people living at the home their description of their personal care needs matched with the details recorded in the care plans and people reported that they considered that their personal care needs were being met. The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 11 The manager plans to introduce a more person centred care planning system where the staff will take on key worker roles and have more involvement in updating the care plans. This should prove beneficial as the present format is limited and does not fully detail peoples’ abilities and this means that peoples’ independence may not be fully promoted. In discussion with the manager she was in agreement with this and said that this would be taken into account in the future. The staff demonstrated that they had a good knowledge of people’s needs and they demonstrated respect and kindness for each person. The staff said that if they notice that a person likes or dislikes anything then they pass this on to the rest of the team and to the trained staff so the care plans can be updated. Peoples’ health care needs are recorded and there is evidence that these needs are met. Records were available to demonstrate that people have access to a range of services such as GP’s, Dentists, Chiropodists and District nurses. The manager works closely with a nurse assessor and a G.P from the PCT who are running a pilot project to prevent unnecessary hospital admissions. The nurse assessor said the home offered good nursing care and that they sought advice appropriately. They said that one person had acquired a pressure sore in hospital, which had healed since being at the home, and each person had the equipment they needed. Visiting relatives said their relative’s health and wellbeing had improved since they had recently moved to the home, and commented, “Her feet and hair have been done and she’s eating better, she’s much brighter”. The care plans contained reviewed risk assessments for all aspects of health including pressure sores and nutrition. We noticed staff assisting four people to move around the home using wheelchairs. The wheelchairs did not have attached footplates. The manager agreed that this posed a risk to people but was common practice. The risks posed to people needs to be assessed for each person individually and action taken to minimise these risks. Medication administration was observed and this met the standard. Improvements had been made to recording procedures since the last inspection to indicate when medication was refused or not given. Only trained staff administer medicines and the guidelines for the recording and storage of controlled drugs are followed. We observed the interactions between the staff and people living at the home to be friendly and caring. The staff said that they try their best to protect people’s privacy when they offer personal support in shared bedrooms. They said they use the screens and they time some care when only one person is in the room. One member of staff said that personal toiletries are kept clearly The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 12 marked and the staff make sure they are only used for that one person. They realised how important that was especially where rooms are shared. The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People who use 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 living at this home can receive visitors as often as they please and keep in touch with their family and friends. People are supported to make their own decisions and choices and they receive a healthy diet. EVIDENCE: Visitors to the home told us that they saw activities taking place in the home. The manager and the staff recognise that not all the service users wish to join in with group activities. Staff said that they had time to sit and talk to people, and that they try to offer individual activities. The home stated in the AQAA that, “Service users have choices in how they want to live in the home. We support the service user with their choices and the activities they want to do” Discussion with people living at the home provided evidence to support this. One person said, “ We are not directed to do things. We are given advice but not made to do anything.” Another person said, “Activities are arranged but I mostly choose to stay in my room”. Only two people who completed a survey The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 14 commented on activities. One person responded that the home always provided activities that they could take part in and one answered usually. Group activities are offered and the staff said that the karaoke machine for sing-alongs was the most popular. The home had books, puzzles and games available, and the staff said they spend time with the people using these. On an individual basis we saw that the manager had made useful links with a local college to meet the needs of one person, and through this ten other people had attended a college activities day. Visiting relatives said that they were always welcomed and the staff knew their names. They said, “The staff are always welcoming and we can come at any time”. The statement of purpose states that visitors are welcome and the provider spoke to a relative on the telephone and helped them to arrange a visit the following week. Another visitor to the home commented, “It is friendly, you can visit anytime and are always offered a cup of tea” People living at the home who can verbally communicate can tell the staff about their preferred routines and in discussion with staff they were able to demonstrate a good knowledge of peoples’ preferences. However more detailed care planning (as discussed in the previous section) would assist the staff to understand how the people who are unable to verbally communicate prefer to spend their time. The staff did say that they used non-verbal communication methods, to try to understand all of the peoples’ needs. People observed and those spoken with told us that they were free to spend their time as they chose and that there were not any restrictions imposed upon them and that they could pursue their own interests. In discussion with people they confirmed that they were free to get up and go to bed at a time of their own choosing and that appropriate support was provided to facilitate this. One person who needed staff support to get up out of bed said that they had originally been getting up later than they preferred and that upon request this was changed. Three out of four people who completed a questionnaire responded that they usually liked the meals at the home and one person answered that they always did. We saw evidence that people are offered choices and although encouraged to eat in the dining room several people had chosen to eat in their rooms and this choice had been respected. Relatives, the staff and a nurse assessor stated that the food is home cooked and presented well. The relatives of one person commented that the food was perfect for their relative at all meal times. They also said that the home was, “feeding her beautifully, she’s now eating well”. Eight of the staff team have attended courses in diet and nutrition. From our own observations and through discussion with the manager we saw that each person gets the support they need at meal times. The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use 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. Satisfactory systems are in place for people to address any concerns or complaints that they may have. Procedures are in place to offer them protection. EVIDENCE: The home has an adult protection policy, which guides the procedure should there be any allegations of abuse. From examination of staff records we saw that staff had received training in abuse awareness during their induction training and this was confirmed in discussion with individual members of staff. Staff said they had attended abuse awareness training as part of their N.V.Q course and they were able to demonstrate that they would act correctly if they suspected abuse. The home had information leaflets on the staff notice board and in the main hallway. Three visiting relatives said the home was safe and secure and that they are always asked to sign in and out. Staff spoken with demonstrated that they were clear about reporting any concerns or complaints to the manager and they said they are confident these would be dealt with properly. They said they could always take any issues to the manager and she had time to support them. Results of staff surveys were The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 16 that all staff responded that they knew what to do if anyone had a concern about the home. Results of questionnaires completed by people living at the home showed that people know who to speak to if they are unhappy about anything and how to go about making a complaint. Comments from people living at the home included, “I can always tell the manager if anything is wrong. I have never had to make a complaint but I am confident that she would deal with any”. Another person said, “Matron will always listen to any complaints”. The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,25 and 26 People who use 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. The physical environment is maintained and furnished to a good standard. The home is clean and tidy with sufficient procedures and systems in place to minimise the risk of cross infection. EVIDENCE: During the visit to the home we saw all communal areas and a selection of bedrooms. The home was clean throughout and there were not any adverse odours present. Toilets and bathrooms were all found to be clean. People living at the home were in agreement that the home is kept clean. All bedrooms seen were comfortable and had been personalised with the person’s own furniture and or belongings, reflecting each persons’ individuality and interests. Bedrooms had been fitted with appropriate aids such as call bells. The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 18 The staff, the people living at the home and their visiting relatives as well as a nurse assessor all said how homely the home was. One staff member said, “It’s not the most luxurious home, but it’s the care that matters and that couldn’t be better”. Relatives said the home had a good atmosphere. The providers have plans to change the building to open up corridors and create more single rooms and this will mean that less people will need to share a room and will provide people with more privacy. During an initial look around the home it was noted that several peoples’ bedroom doors were wedged open. This was discussed with the providers and the manager. They explained that these people preferred their doors to be open and did not like their doors shut when in their rooms. It was agreed that the home would contact Hampshire Fire and Rescue service and seek their advice on whether this was safe practice. The providers agreed that they would take any action accordingly. Infection control procedures were observed to be in place. Liquid soap and paper towels were in place in all communal bathrooms and toilets. Supplies of gloves and aprons were available and staff were observed to use them. The staff have had training in infection control and they were seen to frequently wash their hands. A relative said they always use the alcohol hand gel and the provider replenished this during the site visit. The AQAA states that infection control policies are in place and the staff said they know where to access these. The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use 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. Staff are caring and helpful and are employed in sufficient numbers to meet the needs of people living at the home. They are well trained and undergo a thorough recruitment process. EVIDENCE: The recruitment records of four members of staff who had been employed by the home since the last inspection were examined. These demonstrated that the home follows procedures and carries out all relevant checks on staff prior to recruitment. Staff also receive induction training at the onset of their employment. We spoke to three members of staff who all said that they had they had the time to care well for the people living at the home and to spend time talking to them. The manager confirmed that there were always five carers and a trained nurse on duty and if the home is full to capacity they would have another member of staff on duty to cover the busier times of day. The manager also takes part in care duties and administering medication. Two staff spoken to had completed their N.V.Q courses and one intends to go on to do N.V.Q 3. The AQAA stated that the home is committed to training The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 20 staff and this was confirmed through examination of staff records. One staff member said the manager always had time to help and support them with their N.V.Q course. All staff who returned a survey or who were spoken to during the visit to the home made positive comments regarding the training and support that they received and the level of communication between the staff team as a whole. One person stated, “We are a close knit team who discuss every aspect of our working lives. We also have handovers at the beginning of every shift, and feedback to other carers & the RGN during the day any new information”. The staff files looked at showed that staff had completed mandatory training and specialist courses, these included Risk assessment, Dementia care, Health and safety, Fire safety, Diet and Nutrition, Basic First Aid, Manual Handling and Food Hygiene. The manager uses a system to train the staff and then their assessments are externally verified and certificates issued. The manager stated that they will use a new induction programme for any new staff as the previous one was brief, but the staff said their induction was satisfactory and they said that because they work so well as a team they could go to their colleagues or the manager with any issues. People living at the home told us that the staff listened and acted on what they said. In discussion with people they told us that staff responded quickly to call bells and one person said that they had been given an extra long lead so that they could move around their room and still have access to the bell. Comments from people included, “I am quite happy here. The staff and carers are very nice” and “Very happy with all the staff and the general running of the home”. The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,37 and 38. People who use 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. The home is well managed. The manager is accessible and sensitive to the needs of those living at the home. EVIDENCE: The manager demonstrated that she is committed to continuing improve and develop systems within the home. One health professional spoken with said that the manager had attended courses and implemented beneficial changes afterwards, such as using a tool to assess peoples’ nutritional wellbeing. The staff, people living at the home, their relatives praised the manager and said they found her to be very approachable and friendly and that she gave them time to discuss any issues or problems. Comments from staff included, “It’s a fantastic place to work, we all work as a close team and get on well The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 22 together”, “The manager is very approachable” and “We all communicate really well as a team”. Visiting relatives said that if they mention anything it is immediately dealt with. The manager said she felt supported by the providers and could contact them whenever she needed to. The manager has also established links with other home managers because the area is part of a pilot project by the primary health trust to reduce unnecessary hospital admissions. The AQAA completed by the manager prior to the visit to the home proved to portray an accurate reflection of the both the improvements made since the last inspection and reflected the manager’s ability to identify where further improvement is needed. Various quality-auditing processes are in place. These include the monthly reviewing of care plans, day to day chats with people; regular visits by the providers to assess the running of the service as well as environmental audits. The service will look after small amounts of peoples’ money if they so wish. We checked two peoples’ records and found that accurate records had been kept of all money kept and spent. The providers audit the money and records on a weekly basis and oversee the process. The staff said that they have regular supervision sessions and appraisals and the staff records confirmed this. The staff also said they could approach the manager at any time to discuss their role. One person commented, “In addition to regular supervision meetings we are able to request a meeting with the matron who is very approachable. Any problems that arise from the workers or employers point of view are dealt with immediately”. In general we found record keeping within the home to be satisfactory. Usually the home informs us of any incidents that have occurred at the home. It was noted that they had not informed the Commission for Social Care Inspection of an incident of a break in at the home whereby police were called due to the theft of some staff members money. This incident was discussed with the manager and we saw that it had been dealt with and recorded appropriately with the exception of informing the Commission for Social Care Inspection. The manager was reminded of her obligation to report such incidents and advised to consult guidance issued by the Commission for Social Care Inspection if in any future doubt. The home provided evidence that policies and procedures are regularly updated and that they are kept under regular review. Equally that all equipment used within the home had been regularly checked and serviced. The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 23 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 3 3 The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Extracts may not be used or reproduced without the express permission of CSCI The Birches Nursing Home DS0000062660.V356960.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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