Inspection on 29/01/07 for Birch Hill

This inspection was carried out on 29th January 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 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 Hill 15/12/08

Birch Hill 07/12/05

Birch Hill 12/05/05

Birch Hill 04/11/04

Birch Hill 13/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Birch Hill Norham Berwick Upon Tweed Northumberland TD15 2JZ Lead Inspector Jim Lamb Unannounced Inspection 29th January 2007 10:30 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 Hill DS0000000549.V324418.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 Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birch Hill Address Norham Berwick Upon Tweed Northumberland TD15 2JZ 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) 01289-382216 01289-382087 jenifer.kerr@ben.org.uk BEN - Motor & Allied Trades Benevolent Fund Vacant Care Home 26 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (24) of places Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Birch Hill is situated on the edge of Norham village, which is approximately eight miles from Berwick upon Tweed. There are local bus services to Berwick where there is a main line railway station. Birch Hill is a detached house situated in its own attractive gardens with views of the village and the river Tweed. The Home is owned by BEN Motor and Allied Trades Benevolent Fund and is registered as a charity. Birch Hill provides comfortable, homely accommodation for up to twenty-six elderly people two of whom suffer some degree of dementia. All service users have access to information about the home including inspection reports. Fees for the home range from £380 to £475. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection visit. The inspection took place during the morning and early afternoon. Time was spent talking the manager, deputy manager, four staff and four service users. Service users care records were inspected together with other records relating to the management of the service. A tour of the premises also took place. The service users said that they were happy with all aspects of the care that they receive. Two staff recruitment and training records were also inspected. What the service does well: The home is good at gathering the views of the people who use the service. There is a very stable staff team; the service users spoke highly of the staff and the care that they receive. Service users confirmed that they are able to make choices about their daily routines, including food and activities. Very good relationships have been forged with the local community, health care and other agencies. The home has achieved the Investors in People Award. The grounds are maintained to a very high standard. 99 of the staff have achieved NVQ level 2/3. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide do not provide enough information about the service to enable prospective service users to make a choice about where they want to live. All service users are appropriately assessed prior to admission into the home. All are provided with a written contract explaining their terms and conditions with the home. EVIDENCE: Details of the extra charges, and what these are for, are in the contract given to service users and are agreed prior to their admission. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 9 The homes Statement of Purpose and the Service Users Guide do not contain the full range of information required. The manager is currently reviewing both of these documents. On completion, Information should be made available in a range of formats such as, large print and video. Two service users’ files were checked and each included a full up to date needs assessment. They contained a range of appropriate information. The service users are involved in drawing up both these initial assessments and the home’s subsequent service user plans. For those self-funding and without a Care Managers assessment, a skilled member of staff always undertakes the assessment. The assessment also involves the family or a representative of the service user. The service users said their needs were met and they were happy with the care offered to them. One service user said, “ The staff here are excellent, the food is good, and it’s a lovely place”. The care plans checked confirmed that a range of specialist services was provided to service users. Staff interviewed had had a range of relevant training and experience, 99 have completed NVQ level 2-3. However all require accredited medication training. Intermediate care is not provided. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning system is clear enough to ensure that staff has the information they need to meet the assessed needs of the service users. Monthly evaluations will improve this further. Service users are supported to make decisions about their lives, and take risks to promote their independence. Risk assessments should be signed to ensure they are agreed and understood by all concerned. To promote the health and well being of service users, all staff requires accredited medication training. EVIDENCE: There is a comprehensive assessment in the service users’ care plans. There is also a comprehensive risk assessment of service users. The management of risk takes into account the needs for aspirations for independence and choice. The service user or their representatives should sign all risk assessments. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 11 There are advocacy arrangements, as well as family input to represent service users. Each service user has an allocated key worker. Staff were observed providing personal care to service users in a kind, considerate and helpful manner. Service users spoken to confirmed that staff respects their privacy and treated them in a dignified manner. Care plans are drawn up with service users. Plans are amended and reviewed on a regular basis. It is recommended that service users plans are evaluated each month, and records kept. The care plan is a working tool and to ensure these are fully understood and agreed by service users, and service users representatives, these should also be signed. All service users receive a six monthly review. The service arranges additional reviews when changes take place. Staff spend time with service users to communicate their views to the on-going development of the care plan and the annual review process. Service users care managers and their representatives attend annual reviews. There was a range of comprehensive assessments in the service users’ care records. These included; moving and handling, dependency needs, skin care and, nutritional assessments. Self-advocacy is promoted and service users can access a range of external agencies that promote independence. Service users’ all indicated that they are able to make decisions for themselves. Service users care records showed that they have access to external health care services. G.Ps visit when necessary. Service users are referred for specialist health care if appropriate. All service users receive regular health care checks. The medication systems were examined for ordering, receiving, administering and disposal. All were found to be well managed. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 12 Controlled drugs are also well managed; there are appropriate systems and procedures in place. All staff has received very good in-house medication training, however it is essential that they receive accredited medication training as soon as possible. Information was provided to the manager as to where this training can be accessed. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The meals in the home are good, offering both choice and variety. The service users have opportunities for personal development and leisure activities. They are supported to maintain very good links with the community and their relatives and friends. EVIDENCE: Each service user had practical health and personal skills assessment carried out. All service users participate in this process. Service users are supported to live a normal life in the community. They are supported and encouraged to be in control of their own lives, to enjoy their own interests and hobbies. All service users have the opportunity to participate in social activities held in the home each day. There is an activities co-ordinator, and special events planned are displayed around the home. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 14 The home has its own transport, and regular outings are arranged to local places of interest. All service users are supported to maintain very close links with their families. They can choose who they want to see and when. Daily routines promote independence, choice and freedom of movement. The menus are based on the known likes and dislikes of the service users. At least three hot meals are provided each day. The meals are varied and well balanced. The service users said that the meals were good. Special diets are provided as and when needed. All service users are invited to make comments about the meals in a book provided. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust procedures are in place to protect service users from harm and abuse. Service users complaints are listened to and acted upon. EVIDENCE: There is a complaints procedure. It contains details of how to contact the CSCI to make a complaint, if complainants are not happy with the homes investigation and response. The procedure is written in a way that ensures service users fully understand its contents. Two service users confirmed that they had been given copies of the procedure and that staff listened to their complaints and dealt with them fairly. The home keeps a record of complaints. Since the last inspection visit, there have been two complaints received, these were appropriately investigated and resolved. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 16 The home has a Whistle Blowing policy and the Local Authorities Vulnerable Adults procedures. The home also has a copy of the Department of Health’s document, “NO SECRETS”. All staff has recently received Protection of vulnerable adults training. The Home keeps detailed financial records on behalf of the service users. The organisations Finance Director also carries out audits. Receipts of personal spending are kept. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 22 21 23 24 25 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and safe environment for those living there. The standard and decoration within the home is very good. Communal areas and bedrooms are large, and meet the service users needs. All areas within the home are well maintained, clean, tidy and free from offensive odours. EVIDENCE: The home was very clean, well decorated and well maintained. The grounds were tidy, safe, highly attractive and accessible. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 18 The home meets the requirements of the Disability Discrimination Act and the layout and design is suitable to meet the specific needs of the people who live there. Staff are trained in the safe use of aids and equipment. The home has an appropriate amount of sitting, recreational and dining space. There are enough rooms for a variety of activities to take place. Service users can see visitors in private in their own rooms. There are several smoke-free sitting rooms. Furnishings and fittings were domestic in design and in good condition. Room sizes meet the minimum required. There is space on either side of beds when necessary, to enable access for carers and specialist equipment. The bedrooms are nicely decorated and highly personalised. Three bedrooms have recently been altered and now have en-suite facilities There are plans to add more en-suite facilities in the near future. All bedrooms have opening windows. The rooms were centrally heated and the heating level could be controlled within each bedroom. The home is well lit, clean and tidy and smells fresh. There is a proactive infection control policy and they work closely with external specialists, e.g. infection control, environmental health, and staff ensure that infections are minimised. Clinical waste is properly managed and stored. The kitchen was found to be clean and well organised and stock levels were good. Appropriate checks are carried out including food and fridge temperatures. Water is stored at over 60°C. Valves at water outlets ensure water is provided close to 43°C to prevent scalding. The home was clean and free from offensive odours. The laundry assistant has established a good system for the laundering of service users clothes The laundry facilities are small but well organised, and the washing machine has a disinfection control cycle. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 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 match of well-qualified staff offering consistency of care within the home. There are robust procedures in place for the recruitment and selection of new staff, which helps to protect service users. The staff receives supervision and this provides them with a good understanding of the service users support needs. EVIDENCE: Samples of 4 weeks’ rotas showed the required numbers of staff were on duty: 4 staff between 8am and 9pm with two night staff between 9pm and 8am. The managers are supernumery to the rota. All the staff were over 18 years of age and those left in charge were at least 21. Training needs of staff are identified in supervision and appraisal sessions. The training programme meets The National Training Organisation requirements for the first six months. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 20 All staff receive supervision and appraisals. All staff receives paid training. The service provides a good training and development programme for all employees. The management prioritise training and facilitate staff to undertake external qualifications beyond the basic requirements. Currently 99 of the staff team have achieved NVQ level 2/3. Two staff files were checked. The service continues to operate a rigorous staff recruitment and selection process to ensure that all appropriate checks and references are in place prior to employment. The service sees induction and any probationary period as being an extension of recruitment. Staff turnover is very low; the majority of staff has worked there for many years, several for over twenty years. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is supported by the organisation in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The systems for service users’ consultation are good, and service user’s views are both sought and acted upon. The health and safety of the service users is promoted. The service is aware of equality and diversity and its implications. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager has commenced the registered managers award. She is a qualified nurse. Her goals are fundamental to achieving good quality care for service users. She is already adept at fostering an atmosphere of openness and respect. She has very good support from the homes deputy manager and the staff team. The manager is not yet registered with the CSCI; her fit person interview will take place within the next few weeks. The staff spoken to were all clear about their responsibilities. They had good knowledge of the service users assessed needs. There is a strong ethos of being open and transparent in all areas of running the home. Service users are told when inspections take place and they are shown inspection reports. These are also summarised and discussed in service user meetings. Copies are available for relatives and others to see. The service has sound policies and procedures, which the manager and the organisation effectively reviews and updates, in line with current thinking and practice. Systems are in place to monitor staff adherence to policies and procedures during their practice. The service is aware of equality and diversity and its implications, and strives to promote the diversity agenda within the service. The service continues to operate a good quality assurance system. Service users views are sought and acted upon. Relatives and professionals are also consulted. The service has a good record of meeting relevant health and safety requirements and legislation. The records inspected were found to be appropriately completed. There are appropriate maintenance contracts for the home. Water storage tanks, gas and electrics are checked annually. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13 Requirement All staff requires accredited medication training. The Statement of Purpose and Service User Guide need updating to fully inform service users about the service provision, reflect changes in the service, staffing and alterations to the building. Timescale for action 01/06/07 2. OP1 6a 01/04/07 4. OP7 15 All care plans and risk 01/04/07 assessments should be signed by service users or their representatives. Monthly care plan evaluations must be introduced. Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Birch Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Hill DS0000000549.V324418.R01.S.doc Version 5.2 Page 27 - 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!