Inspection on 17/07/07 for Birch Abbey

This inspection was carried out on 17th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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

Birch Abbey 09/05/06

Birch Abbey 16/03/06

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 Mr Mike Perry Unannounced Inspection 17th July 2007 09:30 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.V345770.R02.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. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 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.V345770.R02.S.doc Version 5.2 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. 9th May 2006 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 3 years. The owners are Melton Health Care Ltd and the Responsible Person is Mr George Daniel Lingard. The Registered Manager is Janet Dean. The service now conducts 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). 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. The current fees for the service are £447 Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a ‘key’ inspection for the service and covered the core Standards the home is expected to achieve. The inspection took place over a period of 11 hours over 2 days. 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 members of care staff on a one to one basis and the registered manager. The inspector carried out a two hour observation on the first day of the inspection using a specialist tool for dementia care which highlights levels of staff interaction, resident well being and engagement with surroundings of the residents observed. The findings are used in parts of the report. Resident surveys were also given out and 10 of these were returned. They were mainly filled in by relatives or by staff assisting residents as necessary due the level of communication of some residents. Comments are used in the report. A tour of the premises was carried out and this covered all areas of the home including the resident’s rooms [not all bedrooms were seen]. 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 home has very good assessment processes so that the staff are aware of residents needs prior to admission and can be confident that hey can care for them. The assessments are detailed and the information also includes assessments from health and social care professionals such as social workers and nurses. Resident are helped to move into the home and made welcome. One relative had to choose a home in an emergency and spoke of the patience and support received when being shown around Birch Abbey, ‘ I had to choose some where quickly and I chose well’. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 6 Relatives feel involved in the care in the home from the admission through to the drawing up of a care plan. staff communicate well and keep relatives involved. There are routine six monthly reviews of the care, which involve relatives. The home liaises well and refers residents for medical opinion and support if required. A visiting district nurse commented that the home supported resident’s health needs and acted well on any advice given. Residents were observed to be appropriately dressed and attention is paid to appearance so that dignity is preserved. Residents are generally very well engaged with their surroundings which have been developed with good practice principals in dementia care. For example chairs are placed so that socialisation is easier and there are orientation aids on the walls and surroundings such as information boards so that residents can feel more secure in their environment and stimulated to explore and interact. There is a strong staff presence and staff interactions were noted to be supportive of resident’s feelings of well being. Staff were skilled at interacting appropriately and assisting residents with activities at their own pace. Relatives reported that there is a relaxed feeling the day areas and that care staff are always on hand. One relative commented ‘‘its really nice here. Its very immediate and friendly and I think everybody is treated as an individual’. A report by a social worker, as part of a review of one resident, said that the person ‘had settled in very well and was blooming in the environment. The quality of life for X is very much improved by being in the home’. The level of attention paid to individuals also extends to other areas of the home such as bedrooms, which were noted to be highly personalised with residents’ personal belongings and mementoes. Each bedroom has a ‘memory box’ outside containing photos and personal items from residents past, which aid in resident identifying their room and also their personal identity. The standard of food at the home is generally 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. Relatives reported that the food is good and one said ‘ my wife has put on weight since being in here’. Another relative said that ‘there is not much choice on a daily basis but if you don’t like a meal they will offer an alternative at short notice’. The residents and their relatives gave good feedback about all staff and the manager. Comments included: ‘I am happy with the support and care my mother is receiving and the staff are helpful and attentive’ ‘The staff are very caring’. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 7 The staff listen. I could not have chosen a better place’. 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. What has improved since the last inspection? What they could do better: There were some anomalies with the medication recording. This meant that it was difficult to make a clear audit of the medication stock. it was also not clear whether some residents had received medications. Meals were reported to be good but in terms of quality of choice there can be improvements. The menus do advertise two meals each dinner time but only one of these is actually cooked so this is misleadingTwo alternative meals and an up to date menu board so that residents are aware of the forthcoming meal should be actioned residents can then make a choice at the time the meals are served. Although generally comfortable for residents the home did have some areas that needed attention and these are listed in the report. The home does not have a maintenance person employed and this needs to be considered. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 8 There are basic standards such as disability access and access to the garden that need to be developed. The owner has plans for the service in the future in terms of major development and these have been submitted to the Commission by the provider. As part of the quality assurance processes in the home the owner must visit monthly and complete a report for the manager as a means of providing feedback and support. None of these were available and must be completed in the future. Fire safety records were examined and some of the checks need to be tightened up. It is recommended that a member of staff complete and more in depth ‘fire marshal’ course so that this can be coordinated. Care staff are involving themselves in laundry duties and kitchen duties in the evening leaving depleted numbers at times. The period between 5 – 8 pm is a concern as there are only 3 staff on duty for this period which can be busy with resident preparing for bed. Care needs may suffer. Some staff felt ‘stretched’ during this period in particular. In terms of the quality of care there should be a rationalisation of staff to ensure consistency of input. This may include additional ancillary cover to free up care staff. 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. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed and admitted to the home appropriately so that their care needs can be met by the staff. EVIDENCE: The manager prior to residents being admitted to the home carries out assessments. Also on the care files seen were referral assessments by both health care professionals and by social workers. The staff are there for aware of the residents needs and can make effective plans to care for them once admitted. The assessments are very detailed and include input from relatives. Relatives confirmed this and also stated that they were involved in six monthly reviews, which the home carries out. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 11 The home also admits people at short notice. This is mainly due the fact that the local social service department refer people for respite care and assessment into one of the beds in the home. The inspector spoke to a family member who’s relative had been admitted in very difficult circumstances. They spoke positively about the welcoming and reassuring nature of the admission and how the manager had spent a lot of time showing the person around the home and answering questions. All of the feedback from relative interviews and comment cards confirmed that the information given at the point of admission had been appropriate and helpful and that they had received contracts and terms and conditions appropriately. One relative said ‘ I had to choose somewhere very quickly and I chose well’. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): All key standards. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a very good standard of health an personal care but there needs to be some attention paid to the medication administration standards in the home so that residents are ensured a safe service. EVIDENCE: Each of the residents has a care plan. New care plans have been introduced since the previous inspection along with a new system of care documentation. The care plans provide an appropriate amount of detail as to how to meet the needs of the residents and were easy to read. Resident’s relatives have the opportunity to contribute to the care plans in writing. The care plans have a section that is for the residents to sign their agreement to their care plan. Relatives spoken with said that they were involved in the care and that staff kept them up to date and informed. One spoke about the 6 monthly reviews of care commenced by the home and how this was a good idea as it was a good way of formalising input by relatives. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 13 Care plan documentation made reference to medical input by GP’s and on one, for example, there had been a referral to a dermatologist following assessment of a skin condition thus evidencing health input. A visiting district nurse was spoken to and felt that staff were supportive of resident health needs and carried out advice and instruction they were given. Residents weight, mobility, medications and diet are regularly reviewed. The manager reported good communication and working relationships with health professionals. Medication policy and administration were reviewed. There were some anomalies with the way staff are recording medicine administration. This meant that it was difficult to track medication stock and tally this with medication records. For example on resident who was on PRN [give when required medicine] had administration records that were very difficult to follow due to ‘NR’ [for ‘not required’] being written on the record which made it difficult to see when the drug had been administered as it obscured initials of staff. This particular medication [diazepam] was also being entered in the control drug register as a further record but an entry was made on the administration record for the previous evening as given but this was not recorded on the drug register. It was therefore almost impossible to complete an accurate audit of stock and what had been given and when. This was compounded by the fact that medication stock had been ‘carried over’ on the medication record but there was no figure attached to this statement. Another resident had 28 diazepam recorded on the administration record as received on 10/7/07. Seven were recorded as given but the stock count was 22, which was confusing. The Controlled Drug book stated 22 in stock although the 28 tablets received had not been added to the running total so the figure is again confusing to follow. Other anomalies were discussed with the manager. There needs to be routine auditing carried out and recorded by the manager so that inconsistencies can be picked up. There also needs to be a consistent policy regarding the management and recording of benzodiazepines [drug group containing diazepam, temazepam, nitrazepam etc]. Following discussion with the manager a CSCI pharmacy inspector will complete an inspection for further guidance. Residents were observed to be appropriately dressed and to be clean so that dignity is maintained. Records kept by staff indicate that there is very good attention paid to residents’ personal care. The visiting nurse said that residents are always seen in their bedrooms and that privacy is maintained. Staff Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 14 interviewed had a clear understanding of the principals of care and how these should be applied. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 15 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): All key standards. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social care in the home is provided with emphasis on people’s individuality so that friends and family feel involved in the home and the care and residents experience high levels of well being. EVIDENCE: As part of the inspection a two hour observational study was undertaken in the lounge so that care could be assessed in terms of the daily interactions of residents with their surroundings and how this effected how well they feel. The study indicated that residents are generally very well engaged with their surroundings, which have been developed with good practice principals in dementia care. For example chairs are placed so that socialisation is easier and there are orientation aids on the walls and surroundings such as information boards so that residents can feel more secure in their environment and stimulated to explore and interact. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 16 There is a strong staff presence and staff interactions were noted to be supportive of resident’s feelings of well being. Staff were skilled at interacting appropriately and assisting residents with activities at their own pace. Relatives reported that there is a relaxed feeling the day areas and that care staff are always on hand. One relative commented ‘‘its really nice here. Its very immediate and friendly and I think everybody is treated as an individual’. A report by a social worker, as part of a review of one resident, said that the person ‘had settled in very well and was blooming in the environment. The quality of life for X is very much improved by being in the home’. Residents were engaged with various activities. The door to the patio garden area was left open and some residents were engaged in gardening. The door to the large garden is secured however and this area is not accessible for residents as the fencing is not secure. This needs to be addressed and the garden area made safely accessible [needs to be considered in terms of future plans for the development of the home]. Some relatives commented that residents do not go outside the home on a regular basis unless relatives take them and so access to a garden is all the more important. The level of attention paid to individuals also extends to other areas of the home such as bedrooms, which were noted to be highly personalised with residents’ personal belongings and mementoes. Each bedroom has a ‘memory box’ outside containing photos and personal items from residents past, which aid in resident identifying their room and also their personal identity. The standard of food at the home is generally 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. Relatives reported that the food is good and one said ‘ my wife has put on weight since being in here’. Another relative said that ‘there is not much choice on a daily basis but if you don’t like a meal they will offer an alternative at short notice’. In terms of quality of choice this should be addressed by the manager. The menus do advertise two meals each dinner time but only one of these is actually cooked so this is misleading. The argument that people with dementia find difficultly in choosing meals in advance, as they often cannot remember their choice, does not mean that they cannot still make choices at the time. Two alternative meals and an up to date menu board so that residents are aware of the forthcoming meal should be actioned residents can then make a choice at the time the meals are served. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 17 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): All key standards. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good complaints process and the home has responded appropriately to concerns raised so that residents are protected. EVIDENCE: Following recommendations on the last inspection report staff have undergone some training in protection of vulnerable adults and abuse awareness. Staff spoken to were able to relate examples of good care practice and understand and report poor practice. Residents are therefore better protected. The complaints file evidenced 4 complaints over the last year. Two of these were investigated under local adult protection procedures and the home had displayed a leading role in both investigations and had taken appropriate action at the end of the process including the referral of one member of staff to the POVA [ Protection of Vulnerable Adults] register. Relatives were aware of the complaints process and this is clearly displayed in the homes information guides. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is comfortable in that bedrooms and day areas are maintained with respect to good practice in dementia care but the service as a whole needs further development in line with existing regulations so that all areas are accessible and safe. 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 and homely 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 Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 19 to keep in their rooms and to be focal points for them to remember things by. Relatives felt that this was particularly good and meant that they could get involved in the process. Bedrooms are fitted with appropriate locks for people with dementia so that privacy can be maintained safely. Some of this work is ongoing and new furnishings were seen in the day areas and there has been a new chair lift fitted. Despite the general environment being comfortable for residents there are signs on the inspection that some further developments with respect to the home are being held back because of proposed future plans involving major development of the site. These plans have been ongoing for a number of years now and more specific dates need to be put forward as the current facility does not meet standards in a number of ways and must be addressed if there is to be any further delay in the proposed plans. For example: • The rear garden is a very good facility but is not accessible currently for residents without staff escort. This is because the fencing is inadequate. Resident’s access to green space is therefore compromised. There is no disability access to the home. A relative commented this on. The existing ramp is to steep and the side of the building is to narrow for any access. The current kitchen facility is domestic in nature and looks ‘tired’ [comment on last environmental health inspection] and is difficult to keep clean. [Cleaning schedules were seen but not signed of and this should be actioned to provide evidence of satisfactory standards]. The kitchen is really in need of upgrading. • • In addition to the above the home is showing some signs of lack of daily and ongoing maintenance. For example the disused couch and debris collected in the drains at the side of the building. Also a bedroom door [pointed out on the inspection], which did not close against the rebate. The bathroom [nr R13 respite room] is not in use presently but should be maintained in a satisfactory condition. It had not been cleaned effectively [dead moths in bottom of the bath] and tiles were missing around bath. The toilet next door had no sign and the lino is badly stained. The lock on one of the GF toilets was small and difficult to manipulate for people who are elderly and have cognitive impairment. The manager advised the inspector that there is no regular maintenance person employed and this should be addressed given the observations. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 20 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): All key standards. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are recruited and trained appropriately so that resident needs can be met. The quality of care can be better improved by the provision of staff numbers at key times in the day. EVIDENCE: At the time of the inspection there were 16 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. There is no laundry person employed. These numbers are depleted in the afternoon when the cook goes of duty [2pm] and again at 5pm when care staff reduces to 3 as the manager leaves at this time. Care staff duties therefore include some kitchen work and laundry work which, by definition, takes time from care work with residents. Some staff reported that they feel particularly stretched at tea time and this can have an effect on care; for example having to have two sittings at tea time as there are not enough staff to supervise everybody having meals together. The staff team consists of 14 care staff and of these 9 now have qualifications at NVQ level so that the home can evidence a core of staff who are competent to carry out care. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 21 The residents and their relatives gave good feedback about all staff and the manager. Comments included: ‘I am happy with the support and care my mother is receiving and the staff are helpful and attentive’ ‘The staff are very caring’. The staff listen. I could not have chosen a better place’. 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 three 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 and staff records had the required police and written reference in place so that residents are protected by the home employing suitable staff. 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 reported that the staff training programme is developing to include providing staff with training in supporting people with dementia care needs and staff interviewed had attended relevant courses. The registered manager has had training in dementia care and the manager has is enrolled on a BSC Honours in dementia care. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interests of residents but there needs to be some attention to future planning and the ongoing management of health and safety so that the existing service can provide consistent standards. EVIDENCE: Janet Dean is the manager of the home. Janet has completed an NVQ in management [at level 4] and is currently undertaking a course in dementia care at degree level she was able to demonstrate recent clinical updates in dementia care and medication procedure and management. She was described in very positive terms by both staff and relatives who find her approachable. she was observed to have very good interactive skills with residents and is able to gain their trust. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 23 There are processess in place to monitor and improve on the quality of the service. The home has a quality assurance check which is carried out annually and which accessess residents and relatives views of the service. The results of this are available in the home and show an overall high satisfaction with the care in the home. Part of this process is for the provider [owner] to complete monthly monitoring visits and produce a report which should be made available to the manager in terms of feedback about the quality of the service. The last inspection recomended that a development plan be produced with aims and objectives clearly identified. This is particularly important given the comments in this report under ‘environment’. Any future plans for the service need to be given dates for completion so that existing services can be rationalised. 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. A policy is available. Health and safety policies, procedures and practices are in place to safeguard the well being of residents, staff and visitors and some of these where reviewed. Some records were inconsistent and not clear: • • • Fire log book did not include monthly checks on fire extinguishers to ensure that they have not been tampered with. Emergency lighting had not been tested in June and the 6 monthly check by simulation of falure of normal lighting supply for a continous period of one hour was not recorded. Ongoing staff training in fire procedure was not recorded and therfore not clear. Any training needs to be coordinated appropriately and it would be recommended that a staff member attends a course to be ‘fire marshall’. A yearly risk assessment of the home was seen but there should be more frequent audits conducted [monthly to tie in with Reg 26 visits by the owner?] and these should be recorded and any action needed should also be recorded. Records need to include checks on window openings and hot water temperatures. [It was noted that wardrobes in bedrooms are not secured to walls which can present as a hazard for people with dementia as they can be inadvertently pulled over]. • These checks are needed to maintain ongoing saftey management of the environment. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 24 Birch Abbey DS0000060016.V345770.R02.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 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 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 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 26 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 OP9 Regulation 17(1)a Requirement Clear and accurate records must be maintained at all times with respect to medication administered to residents. Clear records must be maintained of medicines received into the home. The issues identified in terms of the upkeep of fire safety checks must be addressed. Regular risk assessments must be carried out [monthly] of the home environment as discussed and records maintained with any appropriate action also recorded. Timescale for action 01/08/07 2 3 4 OP9 OP38 OP38 17(1) a 23 13 (4) (c) 01/08/07 01/08/07 30/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 27 No. 1 Refer to Standard • OP9 • Good Practice Recommendations Routine auditing of medication administration records and stock should be undertaken by the manager and records kept. There should be a review of the need t record noncontrolled drug items in the CD book and consistency maintained. 2 3 OP12 OP15 4 5 6 OP27 OP33 OP38 The garden area needs to be safely fenced off so that residents are free to access green space. Alternative meals should be provided each mealtime as planned on the menu. A menu board should be displayed which informs residents of the next meal and offers various choices. The quality of the care could be improved by the allocation of more care staff [or by appropriate ancillary cover] at key times such as the evening period. The provider should record monthly quality visits to the home, and make these available for inspection. A staff trained to act as ‘fire marshal’ would be recommended. Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Birch Abbey DS0000060016.V345770.R02.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!