Inspection on 07/12/05 for Birch Hill

This inspection was carried out on 7th December 2005.

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

The inspector 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 Hill 15/12/08

Birch Hill 29/01/07

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 Anne Urwin Brown Announced Inspection 7th December 2005 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 Hill DS0000000549.V257764.R02.S.doc Version 5.0 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.V257764.R02.S.doc Version 5.0 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 teresa.culbertson@ben.org.uk BEN - Motor & Allied Trades Benevolent Fund Mrs T Culbertson 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.V257764.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th May 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. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one day. It included discussion with the manager, seven residents, five staff, inspection of four residents’ records, other associated records and a tour of the building. Questionnaires were made available before the inspection and seventeen residents and eighteen relatives/visitors completed them. This is a high level of returns. There was a very positive response to the questions with most making very complimentary additional statements about the quality of the service. What the service does well: What has improved since the last inspection? One bedroom has had an en-suite toilet and wash hand basin fitted since the last inspection. The sitting room has been redecorated and new carpet fitted. A new electronically operated care bed has been provided by donation. Birch Hill have achieved the Investors in People award. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 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.V257764.R02.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4 Residents and their representatives know that the home will meet their needs. EVIDENCE: Records show that services are provided for residents with dementia and physical disabilities. Evidence was available that staff seek specialist advice to deal with identified needs of individual residents from records and discussion with staff. Staff have undertaken training in caring for people with dementia and have had other relevant training to meet residents’ needs. There is an experienced team of staff providing support to residents. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 9 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, 9, 10 Each resident has their health, personal and social care needs set out in an individual plan, however these could be improved by providing more information about how needs are met. Residents, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Residents feel that they are treated with respect and that their right to privacy is upheld. EVIDENCE: Each resident’s care needs are recorded within their individual records. More information about how individuals’ care needs are met would improve on the current records. A new draft care plan was available during the inspection and these will provide more detailed information and a more effective review system. Evidence was available that assessments are in place for pressure areas, nutrition, moving and handling and falls. Reviews are carried out regularly. Residents said that they felt satisfied that staff knew what they needed help with. Questionnaires from residents and relatives/visitors were positive about the quality care provided. One person who was a care manager said that she “had not encountered such high standards of care”. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 10 Written guidance is in place in an appropriate form for dealing with medicines. Training has been provided for all staff responsible for administering medicines. Records checked during the inspection were in good order. These showed the date and amount of medicines received and disposed of, as well as those administered. Arrangements for the storage of medicines including controlled drugs are satisfactory. Privacy and dignity are core values referred to in the staff handbook. These are discussed with new staff and form part of the induction training. Staff demonstrated their understanding of privacy and dignity by their actions during the inspection. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 Residents find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Residents receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: The manager confirmed that residents are encouraged to take control of their daily routines. Residents said that they are able to make choices about how they spend their day and said they were satisfied with the activities available. Organised activities are available and residents and staff said that people are able to choose whether or not they are involved. Regular activities include games, video and music evenings, quizzes and fortnightly religious services. Ministers visit the home regularly to see individual residents. The home has a mini bus and estate car available to take residents out. Recently there has been a trip to the Metro Centre shopping. Christmas parties are planned. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 12 New procedures have been drawn up for staff working in the kitchen. These provide detailed information about how staff will meet current guidance and standards. Records of the food provided are kept and these show a good variety of food is available. Residents said that they were satisfied with the food and that a choice is provided. A number of residents have tea-making facilities in their bedrooms and enjoy having some independence about when they have a hot drink. Risk assessments are in place for this. Staff have received food hygiene training and regular updates are provided. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents are protected from abuse. EVIDENCE: Written guidance is in place for dealing with allegations of abuse. A copy of the local authority’s adult abuse procedures is available for staff. Records show staff training in Protection of Vulnerable Adults and two staff are booked to attend an investigation skills workshop in February. No allegations of abuse have been made. One member of staff was not clear about the procedure to be followed in the event of an allegation being made. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 14 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, 20, 21, 22, 24, 25 Residents live in a safe, well-maintained environment. There is access to comfortable and safe indoor and outdoor communal facilities. There are sufficient and suitable lavatories and washing facilities. Residents have the specialist equipment they require to maximise their independence. EVIDENCE: The home is a large detached house that has been extended to provide more bedrooms. There is a programme of routine maintenance and renewal of the fabric of the building. Records of maintenance are maintained appropriately. The grounds are safe accessible and well kept. The building complies with the requirements of the local fire service and environmental health department. The home is well furnished and decorated throughout. There are three sitting areas not including the conservatory. These areas are comfortably furnished and well decorated. One sitting room has recently been redecorated and new carpets laid. New furniture has been ordered. The dining room is spacious and well furnished. Lighting is sufficiently bright and is appropriate to the needs of the residents. The gardens are accessible and some residents said Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 15 they regularly go out for a walk round the garden. Seating is available in the garden. Residents said they are very happy with the facilities provided at the home. Toilets and bathrooms are accessible and appropriate aids are available to meet individual residents’ needs. Four bedrooms have an en-suite toilet and wash hand basin. Individual records confirmed that appropriate assessments are undertaken to identify the need for specialist equipment. A new electronically operated care bed has been provided by donation and is being used by a resident who requires a high level of care. The home provides hoists, grab rails and other aids suited to residents’ needs. Bathrooms and toilets are fitted with appropriate aids. There is a call system point in each room. Each resident has their own room and all rooms are above the minimum size. Residents’ rooms are comfortably furnished and well equipped. Residents are encouraged to bring in personal possessions and rooms showed evidence of this. Residents are given a key to their rooms unless their risk assessment suggests this would not be safe. Lockable storage is available in each room. Residents said they were happy with their rooms. Each resident’s room has a window that can be opened. Central heating is fitted throughout the home and the temperature of radiators can be adjusted. Radiator guards are fitted. Lighting is appropriate throughout the building and emergency lighting is provided. Arrangements for water storage are satisfactory and appropriate checks are carried out. Thermostatic controls are fitted on all hot water outlets. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 16 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, 29, 30 Residents’ needs are met by an appropriate number of staff who are experienced and trained in caring for elderly people. Residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment policies and practice. Staff are trained and competent to do their jobs. EVIDENCE: The staff rota showed that appropriate numbers of staff are available during the day and night. There are usually four staff are on duty in the mornings and evenings and the rota confirms this. There is a senior member of staff on duty at all times. Staff said that there were enough staff to cover the rota. Existing staff work extra hours to cover sickness and annual leave. Two waking care staff are on duty at night. Residents said that they felt there was sufficient staff to meet their needs. No staff under twenty-one years are employed. There are sufficient domestic and kitchen staff. Two driver/handymen are employed. A secretary assists the manager with the administrative tasks. Three quarters of the care staff have completed appropriate training in caring for older people. In addition two staff have almost completed their training and three staff will start next year. Two catering staff have completed qualifications in catering, one at a higher level. One of the kitchen staff is currently undertaking training. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 17 A programme of staff training in care is in place. Staff confirmed that an appropriate induction programme is in place. Copies of the induction were available for inspection. A copy of the training schedule was available and this showed that appropriate training opportunities have been provided for staff. These events included training in Continence, Falls Prevention, Prevention of Abuse, Recruitment and Appraisal, Controlling Costs/Budget Plans, Employment Law, Palliative Care, Loss and Bereavement and Communication Skills. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 18 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 residents live in a home that is run and managed by a person who is fit to be in charge, of good character and is able to discharge her responsibilities fully. The home is run in the best interests of the residents. Residents’ financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The manager is a qualified nurse with a lot of experience of caring for older people. She and the Deputy Manager have completed the Registered Manager Award. Records show that she undertakes appropriate updating training. A written job description is in place for the manager. There are clear lines of accountability within the home and the manager meets regularly with her line manager. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 19 A quality assurance system is in use. In house surveys are used to collect information about residents’ and relatives’ views on the service. The results of the surveys are made available for residents and members of the public. The Home has completed the Investors in People award in June 2005 and the Review Report was available for inspection. An appropriate development has been prepared and shows that there is a cycle of planning, action and review. Policies and procedures are regularly reviewed. Written guidance is in place for dealing with residents’ money. Records are kept that show all transactions of any money held on behalf of residents. Receipts are kept for any transactions. Samples of the money held for residents were checked and these corresponded with the money held. Each resident has lockable storage in his/her room to keep valuables or money safe. Staff have regular training in moving and handling, first aid, fire safety, food hygiene and infection control and records confirm this. Written guidance is in place for Health and Safety and Infection Control. Control of Substances Hazardous to Health is also the subject of written policies and procedures. A health and safety audit is carried out annually by an external organisation and a positive report was available for inspection. Fire alarm and fire equipment tests and servicing records were available in an appropriate form. Risk assessments are carried out for safe working practices and were available for inspection. Accident records are kept in good order. All staff receive appropriate induction training. Staff confirmed this. Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 3 3 3 3 3 3 X STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? NO 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 OP18 Regulation 13 Requirement There is a need to ensure as part of staff supervision that staff are clear about the action to be taken in the event of an allegation of abuse being made. Timescale for action 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Birch Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Hill DS0000000549.V257764.R02.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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