Inspection on 16/03/06 for Birch Abbey

This inspection was carried out on 16th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Birch Abbey 17/07/07

Birch Abbey 09/05/06

Birch Abbey 08/09/05

Birch Abbey 03/03/05

Birch Abbey 19/10/04

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

CARE HOMES FOR OLDER PEOPLE Birch Abbey 55 Alexandra Road Southport Merseyside PR9 9HD Lead Inspector Debbie Corcoran Unannounced Inspection 16th March 2006 11:00 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 Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Birch Abbey Address 55 Alexandra Road Southport Merseyside PR9 9HD 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) 01704 532 788 01704 885 050 Melton Health Care Limited Mrs Janet Dean Care Home 18 Category(ies) of Dementia - over 65 years of age (18) registration, with number of places Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to a maximum of 18 DE(E). The Service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 8th September 2005 Date of last inspection Brief Description of the Service: Birch Abbey is registered to care for up to 18 elderly mentally infirm persons. The home has been in operation since 1989 but has come under new ownership over the past 18 months. The owners are Melton Health Care Ltd and the Responsible Person is Mr George Daniel Lyngard. The Registered Manager is Janet Dean. The service now conduct an assessment on behalf of Sefton Social Services with whom a bed is contracted (reserved) for respite and assessment purposes. The building is a large detached property situated reasonable close to Southport Town Centre. The home currently has no passenger lift (has a stair lift) but there are plans to install a lift over the next year together with other upgrading of the building. The home has 14 single rooms and 2 double none of which have en-suite facilities. The day area is on the ground floor and includes a conservatory extension that overlooks the garden at the rear of the building. There is a small patio/garden area to the side of the building which is accessible and continues on to the rear garden which has been landscaped. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection at the home in this inspection year. The inspection took place over a period of 5 ½ hours and throughout the day the inspector met with the majority of residents and spoke with a number of residents and a number of relatives who were visiting the home. The inspector also spoke with a member of care staff on a one to one basis, the cook and the registered manager. A tour of the premises was carried out and this covered all areas of the home including the resident’s rooms. Records were examined and these included three of the resident’s care plans, staff files, staff training records and health and safety records. What the service does well: The findings of this inspection were generally good. The home felt comfortable, homely, welcoming and relaxed. The home has a good level of information to provide to current or prospective residents about the services provided. New residents are only admitted to the home following an assessment of their needs. This is to ensure the home has the appropriate information so as to determine if the person’s needs can be met at the home. Each of the residents has a care plan which provides staff with information on how to meet the persons needs. The care plans are clearly written and easy to follow. The residents were very positive about all aspects of the home. Resident’s comments included that staff are “lovely” and “very good”. Feedback from relatives was also very positive and staff were described as “like friends” relatives also said that they are made to feel very welcome at the home, that the residents are “well cared for” “happy” and “always well presented” and the home has a “nice happy feel”. The residents have the opportunity to be involved in an activity every day. Activities are planned in advance, structured and well advertised. The quality of food and meals is good and a good variety of wholesome home cooked food is provided to residents. Resident and relatives gave good feedback on the food and said that it was consistently good. The cook is aware of special dietary needs of the residents and of their likes and dislikes of food. Resident’s bedrooms are very nicely presented and furnished with many of their personal belongings. Staff and managers are being provided with some good training opportunities in relation to dementia care and further training is this area is planned. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 6 The staffing levels are sufficient to ensure that the resident’s needs are met effectively and timely and staff were seen to be readily at hand to support residents. The residents are well supported to remain healthy and staff refer to health professionals as appropriate. The manager has worked at the home for the past 5 years and has been the registered manager for the past 2 years. The manager is enthusiastic to provide a good quality service based on best practice for supporting people living with dementia. 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. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 The home has information to provide to prospective residents on the services and facilities provided. Residents needs are assessed prior to moving to the home in order to ensure the home is appropriate in meeting their needs. The home provides one respite care place but does not provide intermediate care. EVIDENCE: The home has a statement of purpose and service user guide to provide current residents and prospective residents with information on the services and facilities provided at the home. The service user guide is written in plain language and covers all relevant information required for example the principles and values under which the home works, the admissions procedure, arrangements for care planning and reviewing the residents care, arrangements for meeting the health care needs of the residents, the physical environment, arrangements for visitors and staff experience and qualifications. Assessment information was looked at for three of the most recently admitted residents. An assessment of needs is in place for each of the residents. These Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 9 assessments have been completed by a senior member of staff at the home. The assessments include information on the residents mental health. The home attains assessments and care plans from relevant professionals for example from care managers and community nurses. In addition to the general assessment there are additional assessments for issues such as any risks associated with the resident’s care. Each of the residents has a separate record of their social history and this describes things such as the person background, previous employment, interests and is used to build a picture of the person and to inform staff as to the activities and interests they could be included in at the home. Standard 6 is a key standard to be assessed however the home provides long term care and does not provide intermediate care. The home does offer one place for respite care which provides a short break for service users. Some service users are referred for this place for an assessment of their needs to be carried out. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 Each of the residents has care plan which is clearly written and easy to follow. In some cases the care plans lack information on supporting the residents with their health care needs. Residents are well supported to remain healthy and staff make referrals to health professionals as appropriate to the resident’s needs. EVIDENCE: Each of the residents has a care plan. New care plans have been introduced since the previous inspection. The care plans provide an appropriate amount of detail as to how to meet the needs of the residents. The plans are easy to read and well constructed. Resident’s relatives have the opportunity to contribute to the care plans in writing. The care plans have a section which is for the residents to sign their agreement to their care plan. For those plans examined the resident’s relatives had signed the care plan. Each of the residents has a monthly review of their care and this is recorded. This monthly review looks at issues such as the persons weight, mobility, diet and health. It was recommended that the manager shows that each of the resident’s care plans are reviewed alongside this. A means to record this was discussed with the manager. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 11 A number of the residents require support with monitoring and managing their diabetes. This support is being provided. However, the details of how this support is to being provided is not included in the residents care plans. The manager was advised that care plans must include all relevant information on how to support the residents to remain healthy. Some discussion took place with the manager regarding supporting the needs of residents who may have aggressive behaviour. The manager was advised to develop guidelines for supporting residents (as appropriate) with their behaviour and include these in their care plan. These guidelines should include information on what might trigger the behaviour followed by guidance for staff on how to then support the person with an aggressive episode. The manager has referred for professional support with these issues and understands the importance of re assessing the needs of residents. Records showed evidence that the residents are well supported to remain healthy. Staff refer to health professionals and there are regular visits from G.Ps and district nurses. Residents weight, mobility, medications and diet are regularly reviewed. The manager reported good communication and working relationships with health professionals. Medication was not assessed on this occasion. However, during a tour of the premises it was noted that a prescribed cream was left in a communal bathroom. This was pointed out to the manager as needing to be stored safely. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, 15 Residents are well supported to be involved in activities. Residents are encouraged to maintain their independence and exercise choice. A choice of good quality home cooked food is provided to the residents and the catering arrangements and kitchen are well organised. EVIDENCE: Each of the residents has a file specifically for information about their social, cultural, recreational and vocational background. This information is used to give care staff information on the resident’s background and to inform staff as to the interests and activities which may be of interest to the person. Each of the residents has an activities calendar in their bedroom. These show that there is some form of activity for residents to be involved in every day of the week. These activities include music, sing songs, video, reminiscence, nails and beauty, arts and crafts and entertainers are brought in to the home. During the inspection an entertainer was at the home for a couple of hours. The majority of residents were together in the lounge for the entertainment and many of the residents appeared to enjoy it. The home has a resident’s notice board and this advertisers forthcoming activities / events. Staff described a recent 80th Birthday party for one of the residents and it appeared that thought and effort had gone in to the event. A daily record is kept of activities which the residents have been involved in. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 13 A member of care staff is responsible for co-ordinating activities. This member of staff had undertaken a training course for providing activities for people living with dementia . A number of examples could be seen of how residents are encouraged to exercise choice and control and maintain their independent living skills. Residents are reported to make daily choices such as when to get up, go to bed and have a choice of meals. Residents are encouraged to get involved in some household tasks for example making their bed and washing dishes. This is aimed to encourage them to use their skills and participate in the daily routines of the home. There is a resident’s notice board which includes lots of information for residents and shows the date and which staff are on duty as a means to help the residents who have difficulty with orientation. The home clearly encourages relatives of the residents to be included in decision making and examples where given of when independent advocates have been used to act on behalf of residents. Information on advocacy services is freely available in the home. The standard of food at the home is good. The main meal of the day is served at lunch time and the cook prepares fresh home cooked food. The meal was nicely presented and appeared appetising. The cook went around the dinning room during lunch to offer the residents seconds to what were already good sized portions. The residents appeared to enjoy their food. Comments form both residents and their relatives on the food and meals offered were good. The home has a two week menu and this shows that a varied and well balanced diet is provided. The cook knows the dietary needs of the residents and their likes and dislikes. A relative commented that the husband of one of the residents is offered the option of having a meal with his wife when visiting the home. Relatives also said that they are made welcome and offered refreshments when they visit the home. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Policies, procedures and practices are in place which aim to prevent an abusive, neglectful or issue self harm from occurring. Staff are given instruction on adult protection but have not been provided with training in this. EVIDENCE: The home has a policy and procedure on adult protection. This was examined and found to be clear and concise and includes details for contacting relevant agencies. The home also has a copy of Sefton Local Authority’s adult protection procedures. The manager reported that new staff are provided with information on adult protection during their induction to the home. Staff should also be provided with adult protection training in addition to this. The home also has a ‘whistle blowing’ policy which enables staff to raise concerns about practice without being identified. At the time of inspection this policy was pinned to the notice board for all staff to read and sign as having read it. During discussions with a member of staff they were able to confirm that they were aware of the whistle blowing policy and of how to report suspected abuse. The manager has guidelines for referring staff to the ‘protection of vulnerable adults’ list if reason to do so arises. The manager gave an example of having used adult protection procedures on an occasion in the past and through this she showed that she has a clear understanding of the procedures and routes for reporting potential abuse. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24, 25 The presentation of the home continues to improve. Residents are provided with a safe, comfortable and homely environment in which to live. Residents bedrooms are nicely presented and personalised with some of their own belongings. EVIDENCE: A tour of the premises was carried out. The home feels domestic and welcoming. The home has undergone a significant amount of refurbishment over the past couple of years and provides a safe well maintained environment for residents. The home provides 14 single bedrooms and 2 double bedrooms. None of the bedrooms have en suite facilities. Each of the residents bedrooms were viewed and all were well presented. The standard of decoration and furnishings in all of the rooms was good. Residents are encouraged to bring personal belongings to keep in their rooms and to be focal points for them to remember things by. One of the resident’s relatives said that they had been asked to provide some personal items for their relative which were significant from their past. The Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 16 majority of bedrooms are fitted with locks and it is planned that locks will be fitted to the remaining few in the near future. The laundry has been upgraded since the previous inspection. There are plans for an extension to the home to expand the lounge area and provide a number of extra bedrooms. These plans are not finalised as of yet. The only issue to be addressed following this inspection is the need for some refurbishment to a first floor w.c. This was identified to the manager at the time of the inspection. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Staff numbers are appropriate and service user’s needs are being met effectively and promptly. Some members of the staff team are being provided with training in dementia care thus enabling them to understand and meet the needs of the residents more effectively. Staff require training in some of the core skills relating to their work. There is room for improvement in the staff recruitment and selection procedures which relate to protecting residents. EVIDENCE: At the time of the inspection there were 17 residents at the home and they were being supported by 3 carers (1 of whom was a senior carer). There was also a cook, a domestic and the registered manager on duty. The manager reported that there is one vacancy in the staff team as the staffing is going to be increased to include an additional senior carer. Staff turnover for the past 12 months was discussed. This was not in excess and gave no cause for concern. The staff team consists of 10 care staff and of these 2 have attained a National Vocational Qualification (N.V.Q) in care and a further 3 were undertaking the award. In addition to this the manager reported that a small number of staff were studying social care studies. The registered person should aim for 50 of the staff team to attain an N.V.Q in care in order to meet the national minimum standards. The residents and their relatives gave good feedback about all staff and the manager. Care staff were described as “lovely” and “very good” by the residents and described as “like friends” and “very welcoming” by relatives. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 18 Staff were observed to be warm and respectful with the residents throughout the course of the inspection. Staff were present in the lounge throughout the inspection and were readily available to meet the needs of the residents. Staff files were checked for two new members of staff in order to assess the staff recruitment and selection procedures at the home. The files showed that pre employment checks are being carried out but these need to be improved on. Pre employment references are attained but the manager must ensure that these references are appropriate. The details of this were discussed during the inspection. The manager also needs to ensure that the ‘protection of vulnerable adults list’ (Pova list) is checked prior to new staff starting work. Criminal Records Bureau (CRB) disclosures were on file however these need to be updated. The manager provided information on staff training. This shows that the training opportunities and training needs of the staff team have been identified. The manager should review the level of staff training in some core health and safety related skills. The manager reported that the staff training programme is developing to include providing staff with training in supporting people with dementia care needs. A member of staff reported recent training in supporting people who have Parkinsons, and in providing activities for people living with dementia. Two members of staff are due to attend a 3 day course on supporting people with dementia. The registered manager and deputy manager have had training in dementia care and the manager has enrolled to commence a BSC Honours in dementia care. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36, 38 The home has a system for regularly checking on the quality of the service provided and this includes surveying residents and their relatives. The home does not manage money on behalf of residents. Where a resident requires support with their money a representative from Social Services or advocate is used. Staff are being regularly supervised on a one to one basis with the manager of the home. Policies, practices and procedures are in place to safeguard the health, welfare and safety of service users and staff. A small number of health and safety issues need to be addressed. EVIDENCE: The home has a quality assurance check which is carried out annually and an additional check is carried out every six months using a self audit. The annual quality check includes surveying the residents and their representatives on the quality of the service. Feedback from this process is published and distributed. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 20 It is recommended that an annual development plan is produced which reflects aims and outcomes for residents. The manager is enthusiastic to provide a good quality service based on best practice for supporting people living with dementia. The home does not manage any money for residents. Resident’s relatives are invoiced for any additional costs for activities, hairdressers, chiropody etc. This arrangement is made clear to residents and relatives and is provided in the residents guide to the home. Where a resident does not have a relative or representative to support them with their finances then care managers and advocates are used for this purpose. The manager has introduced one to one supervision meetings with each member of the staff team. Health and safety policies, procedures and practices are in place to safeguard the well being of residents, staff and visitors. Health and safety records were checked. These showed that fire safety checks are in place and up to date. The home has a current gas safety certificate and a current electricity safety certificate. Hoisting equipment had been regularly serviced. Thermostatic valves are fitted to hot water outlets and these are set at a safe temperature. However, it is recommended that water temperatures are checked and recorded at regular intervals to ensure these are appropriate in addition to this. At the previous inspection is was identified that staff required fire safety training. This has not been provided to date. The manager provided dates when this is scheduled to take place in April. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 21 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 3 x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 3 x x x 3 3 3 x 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 x x 3 x 3 x x 2 Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered person must ensure that care plans include information on how to meet the resident’s health care needs. Care plans must include guidelines for supporting the person with their emotional / behavioural needs. Care plans must be regularly reviewed. The inspector would require a newly updated plan of works to be completed with estimated completion dates as part of the action plan for the home. The manager must ensure that staff are provided with adult protection awareness and training linked to Sefton’s adult protection procedures. All staff employed must receive the necessary POVA and CRB checks as well as adequate written references prior to full employment in the home. All staff must receive training updates in fire safety. Outstanding DS0000060016.V287524.R01.S.doc Timescale for action 14/05/06 2 OP19 23 To be included in returned action plan 14/08/06 2. OP18 13 (6) 3. OP29 19 (1) (b) 14/05/06 4. Op38 23 14/06/05 Birch Abbey Version 5.1 Page 23 5. OP30 6. 7 8. OP19 OP38 OP9 18 ( c) (1) Staff training must be reviewed and staff must be provided with training in core skills as appropriate to their role. 23 (2) (b) The registered person must ensure refurbishment is carried out in the first floor wc 13 (4) (c) Water temperatures should be checked and recorded at regular intervals. 13 (2) All prescribed medication must be stored appropriately. 14/08/06 14/06/06 14/05/06 14/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP28 OP33 Good Practice Recommendations The home should aim to achieve 50 of care staff to be NVQ trained by the end of 2005 The registered person should develop an annual development plan for the service linked to outcomes for residents. Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Birch Abbey DS0000060016.V287524.R01.S.doc Version 5.1 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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