CARE HOMES FOR OLDER PEOPLE
Birch Abbey 55 Alexandra Road Southport Merseyside PR9 9HD Lead Inspector
Mr Mike Perry Unannounced Inspection 9th May 2006 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 Birch Abbey DS0000060016.V294829.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. Birch Abbey DS0000060016.V294829.R01.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.V294829.R01.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. 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 2 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 assessments 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 reasonably 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. The current fees for the services at Birch Abbey are £426. Birch Abbey DS0000060016.V294829.R01.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 entire core Standards the home is expected to achieve. The inspection took place over a period of 10 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 and the Provider. 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 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. Those relatives interviewed stated that the information given to them during the addmission process was good and helped them and the residentt come to terms with being admitted to a care home and to settle in to the home. Assessments are carried out prior to and following addmission and these are comprehensive and assist staff in drawing up a care plan. The home also access’ information and asssments from social and health care professionals. All residents have a care plan and the manager is still working on the care planning format in order to make the process easier to use for both staff and resident and there representatives. Relative’s interviewed were clear that the staff keep them updated regarding any changes that occur in terms of the general care. Care plans are easy to read and care interventions described are clear and personalised for example loves a cuddle, can sit out on her own for periods [when agitated ]. Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 6 One resident was being cared for in bed and was very frail. There had been good liason with the GP and the distict nurse team were involved with the care and were visiting 3 times weekly. Another resident was receiving input from the Community Psychiatric Service [CPN] for issues around challanging behaviour. Generally there was good liason with health care services and appropiate support was in place. The personal care of residents was noted to be good. residents were observed to be clean and well presented. relatives commented that the staff approach was always suportative and friendly. One commented that the care is excellent and the staff couldnt do more. Medicine procedure, training of staff and storage were all reviewed. The drug recording sheets seen evidenced good practice with all medicines clearly recorded. The observation of the residents evidenced a general feeling of well being and that they were comfortable with the care staff. Staff reported some training in the provision of activities for residents and understoood the importance of encouraging daily living tasks as activities as well as creative and reminiscence pastimes. Relatives appreciated the work in this area although some comments recieved indicate that more can be developed. residents were observed in the garden during the inspection and some were assisting with the activities. Comments from residents and relatives were very appreciative of the support offered by staff. comments included: there is always something going on its nice here - I feel safe people [staff] are very kind to me staff are always freindy and supporttive The standard of food at the home is good with meals presented well and comments recived from both residents and relatives were positive. Relatives interviwed were not wholly aware of the complaints procedure but said that they felt confident that they could approach the manager if they had a problem. The complaints procedure is displayed in the home and in the Service User Guide. The manager has had experience of being involved with and using the adult protection procedures. A recent case in the home has ensured that residents rights have been upheld and the home acted appropiately. The home feels domestic and welcoming. All bedrooms very well personalised. It is clear to see that staff have spent some time getting family to bring in photos and ornaments and varios memorabillia. All areas are clean and tidy. Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 7 Externally the front garden is well presented. The back garden is used fairly frequently and enclosed. some garden furniture available and residents were seen to be using the garden at the time. Day areas are pleasant and relaxed. good use of space divided by placement of chairs. Residents and relatives interviewed felt comfortable in the home and said that it was always welcoming and homely. 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 relatives. Staff were present in the lounge throughout the inspection and were readily available to meet the needs of the residents. Janet Dean is the manager of the home. Janet has completed an NVQ in management [at level 4] and is seeking to commence a course in dementia care at degree level. 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 there trust. There are processess in place to monitor and improve on the quality of the service. These include accessing residents and relatives views of the home so that the service can be developed with their needs in mind. Health and safety policies, procedures and practices are in place to safeguard the well being of residents, staff and visitors. What has improved since the last inspection?
Following requirments from the previos inspection it was noted that any incidence of aggression are recorded on an identified form and some sort of plan made. The manager has disccused the complaints procedure and the adult protection procedures with staff who are now more aware of the process involved. Shared rooms seen and curtains now in situ folowing previous requirements so that privacy is upheld The laundry upgrading work has been completed. 2 washing machines and 2 dryers are available. Staff files evidenced that good recruitment checks are made on staff employed at the home. Following previos requirements the manager is now aware of the need for standard checks to be made.
Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 8 The manager has introduced one to one supervision meetings with each member of the staff team. staff interviewed felt that this was suppotative and usefull although in its early stages. At previous inspections is was identified that staff required fire safety training and this has now been carried out. What they could do better:
The home are very good at assessing care needs and risk to residents but some of these assessed needs were missing from the care plans so that instructions to staff as to the care required was missing. One resident was poorly and the basic observations such as fluid intake and diet were not recorded up to date. The importance of this was discussed with the manager. There has been a lot of work completed by the Provider and Manager over the past 18 months – 2 years in both upgrading and developing the home. There now needs to be a written service development plan for the next year that clearly lays out the progress the service needs to make. All residents need a contract on admission to the home. Contracts have now been finalised and this should now occur as a matter of course. The language used on some care plans needs to be looked at so that judgmental comments are not made which can be prejudicial to residents. Some reference needs to be made on the induction programme to dementia care so that new staff are given some introduction to the resident group. The home is keen on training and should aim to meet the standard of 50 Staff trained to NVQ level. There are some recommendations in the report for a policy statement on the management of resident’s finances and some checks to be recorded in the fire log book. Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 9 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.V294829.R01.S.doc Version 5.2 Page 10 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.V294829.R01.S.doc Version 5.2 Page 11 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, [standard 6 not applicable] The quality in this outcome area is good. The home provides good information for prospective residents and their relatives so that an effective chioce can be made to move into the home. Contracts have been issued recently but need to be given at the point of moving into the home for each new resident. Appropriate assessments are carried out by the home, which include social service and / or health assessments so that the home is better able to ensure care needs will be met. 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,
Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 12 arrangements for meeting the health care needs of the residents, the physical environment, arrangements for visitors and staff experience and qualifications. those relatives interviewed stated that the information given to them during the addmission process was good and helped them and the residentt come to terms with being admitted to a care home and to settle in to the home. this was particularly the case with the time the staff spent in explaining things to them. the relatives interviewed and those that replied to the comment cards had not recieved a contract until recently. The manager explained that the new owner had taken some time to draw up contracts as he wanted to ensure they were appropiate. Assessment information was looked at for three residents. An assessment of needs is in place for each of the residents. These assessments have been completed by a senior member of staff at the home. The assessments include information on the residents mental health. assessments are also completed prior to residents being addmitted although in the case of the emergency respite bed this is not always possible. 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. Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 13 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): 7,8,9,10 The quality in this outcome area is adequate. The home manages the health care needs of residents satisfactorily but some care needs are not included on care plans and daily monitoring needs to be consistent so that all care needs are met. Personal care needs are met consitently so that residents are treated with respect and their dignity maintained. EVIDENCE: Care plans for 3 residents were looked at in detail. All residents had a care plan and the manager is still working on the care planning format in order to make the process easier to use for both staff and resident and there representatives. At present there is a service user agreement which is a condensed version of the care plan used to formalise the discussion process with the relatives. These were seen and were signed by relatives. Relative’s interviewed were clear that the staff keep them updated regarding any changes that occur in terms of the general care. Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 14 Risk assessments carried out for moblity and other risks in terms of daily living. some risks identified do not appear on care plan such as risk of falls identified but no corresponding entry on the care plan for 2 residents. also prone to bowel impaction was assessed for 1 resident but again no care interventions on care plan. Care plans are easy to read but some launguage could be termed disciminatory such as desribing aggression for one resident as being nasty and having temper tantrums. use of language discussed with manager. care interventions described are clear and personalised loves a cuddle, can sit out on her own for periods [when agitated ]. following requirments from the previos inspection it was noted that any incidence of aggression are recorded on an identified form and some sort of plan made. Not all of these forms were filled in properly however and the care interventions were not always described on the care plan. Reviews of the care plan are indicated on a form which consists of dates but no notes. the concept of evaluation was discussd with the manager and agreement reached that this should be a discussion and evaluation of progress made against the goals set on the care plan. One resident was being cared for in bed and was very frail. there had been good liason with the GP and the distict nurse team were involved with the care and were visiting 3 times weekly. feedback from the team was that the home were appropiate in there referal and the communication with the manager and staff in the home was good. It was observed that the monitoring of this residents fluid and diet intake was through charts in the residents room. staff had not completed these however for some time. the care plan incorporated reference to the health care of this resident although the district nurse team maintain their own notes. Another resident was receiving input from the Community Psychiatric Service [CPN] for issues around challanging behaviour. another resident was being cared for in bed presently due to bad chest. there was a pressure relief mattress provided from District nurses. the relative reported that the care was excellent and the staff couldnt do more. The personal care of residents was noted to be good. residents were observed to be clean and well presented. one resident discussed the cardigan and dress she was wearing and staff commented that she had been assited to choose these items herself from the wadrobe. shared rooms were noted to have new curtains in place which divided the room and helped ensure privacy. relatives commented that the staff approach was always suportative and friendly. Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 15 Medicine procedure, training of staff and storage were all reviewed on the site visit. Recent updating for all senior care staff has also introduced regular 2 weekly auditing of stock. The drug recording sheets seen evidenced good practice with all medicines clearly recorded. There can be possible confusion as not all staff record their full initials on the record sheets and this can be confused with some of the medication key codes. Discussed with the manager. There are no residents self-medicating due to level of confusion but there is an assessment carried out when residents are admitted. Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality in this outcome area is good. 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 EVIDENCE: The observation of the residents evidenced a general feeling of well being and that they were comfortable with the care staff. Care staff were observed to be always in attendance and spending time chatting and interacting with residents. for example sat doing nail care. Staff reported some training in the provision of activities for residents and understoood the importance of encouraging daily living tasks as activities as well as creative and reminiscence pastimes. some of the later was evidenced by displays in the home which one residnert was able to discuss with the inspector. There is a programme of activities which continues to develop and includes outside entertainers and well as regular outside activity in the garden. relatives appreciated the work in this area although some comments recieved indicate that more can be developed. residents were observed in the garden during the inspection and some were assisting with the activities.
Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 17 Comments from residents and relatives were very appreciative of the support offered by staff. comments included: there is always something going on its nice here - I feel safe people [staff] are very kind to me staff are always freindy and supporttive 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 appetising. The cook went around the dining room during lunch to offer the residents second helpings. The residents appeared to enjoy their food. residents needing assistance were noted to be given patient attention by staff. there was some discussion around the need to set tables and this should include condements for residents. Comments form both residents and their relatives on the food and meals offered were good. Relatives said that they are made welcome and offered refreshments when they visit the home Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 18 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): 16,18 The quality in this outcome area is adequate. There is a complaints procedure including action for more serious allegations so that residents rights are upheld and people feel that concerns are addressed. The issue of formall training for abuse awarness for staff still needs to be adressed. EVIDENCE: Following requirements from the last inspection the manager has disccused the complaints procedure and the adult protection procedures with staff. this was evidenced from both training files and staff interviews. The manager is still to arrange further training but has been in touch with the training providers. Relatives interviwed were not wholly awre of the complaints procedure but said that they felt confident that they could approach the manager if they had a problem. the complaints procedure is displayed in the home and in the Service User Guide. The manager has had experience of being involved with and using the adult protection procedures. A recent case in the home has ensured that residents rights have been upheld and the home acted appropiately. some feedback from the relative involved was that they were not informed at an early stage of the process. this was discussd with the manager and it was clear tha this responsibilty fell to external professionals. The manager will give feedbak to the adult protection team with respect to this issue.
Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 19 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): 19,26 The quality in this outcome area is adequate. The presentation of the home continues to improve. Residents are provided with a safe, comfortable and homely environment in which to live. There is still some upgrading planned which the Provider is aware of. 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 All bedrooms very well personalised. It is clear to see that staff have spent some time getting family to bring in photos and ornaments and varios
Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 20 memorabillia. all rooms are clean and tidy. Shared rooms seen and curtains now in situ folowing previous requirements so that privacy is upheld externally the front garden is well presented but no disabled access. Ramp can be accessed at the rear of the building. The ramp leading to the rear of the buiding looks very steep. The back garden is used fairly frequently and enclosed. some garden furniture available and residents were seen to be using the garden at the time. The laundry upgrading work has been completed. 2 washing machines and 2 dryers are available. Red alginate bags are available. there is a wash hand basin but no handtowels [paper]. there is also no paper hand towels in shared toilets. Day areas are pleasant and relaxed. good use of space divided by placement of chairs. conservatory gets hot in summer and there is a need to use fans. The home has no passenger lift. less independent residents are managed on the ground floor. The bathroom on the ground floor is a well used shower facility with shower chair which can also be used over the toilet. There were no maloderous smells in the home which presents as clean and fresh. All floors in bedrooms are laminated and easily cleaned. The cleaner was observed throughout the day and had a good rapport with the residents. The projected extention work previously discussed with the owner has not been actioned as yet althouth some alternative plans were discussed. Residents and relatives interviewed felt comfortable in the home and said that it was always welcoming and homely. some comments received were that any future developments need to include a quiet lounge for more privacy when visiting. Disabled access could also be improved. Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 21 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 The quality in this outcome area is good. 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 although basic awareness needs to be evidence as part of the induction process. Staff are recruited appropriately so that residents are protected. EVIDENCE: At the time of the inspection there were 14 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. staff share some of the work in the kitchen as the cook is off duty at 2pm. they also do laundry duties. staffinterviewed were clear that this work did not currently impinge on there ability to provide care for residents. The staff team consists of 10 care staff and of these 2 have attained a National Vocational Qualification (N.V.Q) in care. the manager is aware that more work needs to be done to meet the standard of 50 care staff trained to NVQ standard but most care staff have stated or are starting courses in he near future.
Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 22 Staff interviewed were pleased with the training provided and one commented theres lots of training. one staff interviewed has complted a 3 day course in dementia care including challenging bevaviour. Also attended training for activities for residents and has organised some of these especially the art based activities. The manager was described by all staff as very keen on training and very suppotative. other recent traing includes fire saftey and health and saftey. Newer staff reported good induction training and staff files inspected support this. staff did report little on dementia care awarness as part of the induction however. this was discussed with the manager and needs to be evidenced on the induction check list. Staff reported that they had been recruited following checks and references and they felt this process was thorough. Following requirements from the previous inspection the manager is aware that all new staff must receive Criminal Records [CRB] checks and POVA [ Protection of Vulnerable Adults ] clearance prior to employment. staff files evidenced good standards. Staff interviewed displayed Knowledge of how to deal with more challenging behaviour. one staff desribed interventions when residents become agitated try to calm them down - talk slowly dont shout - speak clearly so that you can be understood. residents are reassured by this. 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 relatives. Staff were present in the lounge throughout the inspection and were readily available to meet the needs of the residents. Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 23 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): 31,33,35,38 The quality in this outcome area is adequate. The manager of the home displays the skills and knowledge to manage the home so residents and staff needs are supported There are systems in place so that the quality of the service can continue to be improved with reference to service users needs and comments. EVIDENCE: Janet Dean is the manager of the home. Janet has completed an NVQ in management [at level 4] and is seeking to commence a course in dementia care at degree level she was able to demonstrate recent clinical updates in demetia 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 there trust. Janet has shown an ability to manage difficult processess
Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 24 as evidenced by the instigation of adult protection procedures following a recent allegation. 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 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 [ conducted every 6 months] the results of the last survey were seen on display. The last inspection reccomended that an annual delvelopment plan be produced with aims and objectives clearly identified and this has not yet been actioned. 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 full policy stament shouold be listed in the policy document for the home. The manager has introduced one to one supervision meetings with each member of the staff team. staff interviewed felt that this was supotative and usfull although in its early stages. Health and safety policies, procedures and practices are in place to safeguard the well being of residents, staff and visitors. The previos inspection and the provision by the manager of the pre inspection data sheet evidences that saftey certificates are kept up to date. [current gas safety certificate and a current electricity safety certificate. Hoisting equipment had been regularly serviced]. At previous inspections is was identified that staff required fire safety training and this has now been carried out.. Fire saftey records were seen and some discussion took place for amendments to records although over all monitoring was good with fire risk assesssments in place. Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 X X X X X X 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 X 3 X 3 X X 3 Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 26 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 Timescale for action 01/06/06 2 OP8 12 4. OP19 23 All assessed care needs must be included on the care plan, particularly those associated with risk. All care plans need a clear evaluation recorded as discussed. Any care needs must be 01/06/06 monitored as per care plan including any clinical observations such as fluid charts, diet charts and pressure relief charts. The inspector would require a 01/07/06 newly updated plan of works to be completed with estimated completion dates as part of the action plan for the home.[ requirement from last inspection not yet met] RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No.
Birch Abbey Refer to Good Practice Recommendations
DS0000060016.V294829.R01.S.doc Version 5.2 Page 27 1. 2 3. 4 5. 6 7 8 9 10 Standard OP1 OP7 OP18 OP18 OP27 OP28 OP30 OP33 OP35 OP38 All residents should receive a contract on admission to the home. The review of the care planning system in the home should take account of the discussion at the inspection and the comments in this report. Recommend that some feedback be given to the adult protection team in terms of outcomes for the relative of the resident concerned in the recent investigation. Planned training for staff on abuse to take place. In terms of quality it is recommended that a week end cook is employed. The home should aim to achieve 50 of care staff to be NVQ trained by the end of 2005 Awareness of dementia should be addressed in the induction programme as discussed. The Manager / Provider should produce an annual development plan for the home. The homes policy on management of resident’s monies needs to be referenced in the policy file. The fire logbook should contain a record of monthly inspections of the fire extinguishers and the 6 monthly checks for emergency lighting [test of 1 hour duration]. Birch Abbey DS0000060016.V294829.R01.S.doc Version 5.2 Page 28 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.V294829.R01.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!
