Inspection on 01/11/05 for Birch Holt Retirement Home

This inspection was carried out on 1st November 2005.

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 Holt Retirement Home 28/08/07

Birch Holt Retirement Home 16/10/06

Birch Holt Retirement Home 26/01/06

Birch Holt Retirement Home 10/12/04

Birch Holt Retirement Home 15/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Birch Holt Marlpits Lane Ninfield East Sussex TN33 9LD Lead Inspector Rebecca Shewan Unannounced Inspection 1st November 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 Holt DS0000021052.V262859.R01.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 Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Birch Holt Address Marlpits Lane Ninfield East Sussex TN33 9LD 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) 01424 892352 Mr Terence Fusco Mrs Anne Heathcote Mr Terence Fusco Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty-six (26) Service users must be aged sixty-five (65) years or over on admission Date of last inspection 10th December 2004 Brief Description of the Service: Birch Holt is registered to provide care for up to twenty-six older people. The home is located on the rural outskirts of the village of Ninfield. The home is a large detached house, which provides accommodation over two floors. Twenty-two of the bedrooms are single and two bedrooms are double. There are a variety of communal areas and the home is well maintained and comfortably furnished, for the needs of residents. The garden area is wellmaintained and accessible to service users. Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and early afternoon of the first November 2005. Before the inspection papers held by the Commission for Social Care Inspection were read. The inspection of the home took six hours. A tour of the whole home was undertaken and one of the Registered Managers, the Care Manager, the Deputy Care Manager, two staff and two service users were spoken with. There were twenty-three service users living at the home at the time of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The Service Users Guide will require updating to include the amended Complaints procedure. The home should ensure that Service users care plans are signed by service users, where it is impracticable this must be documented. The home should make measures to ensure that service users care plans are consistently reviewed on a monthly basis. The home should review how it records the administration of controlled drugs. Staff recruitment must comply with the Care Homes Regulations 2001 (Outstanding from previous Inspection). The home should make provisions for Portable Appliance Testing (PAT) to be carried out within the home. Urgent action should be taken by the home to ensure; that all hazardous products are kept in accordance with C.O.S.H.H regulations, that the homes boiler cupboard is kept Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 6 locked at all times when a staff member is not present, that all products such as talcum powder and shampoo are clearly labelled with the residents name and any products, which could be deemed as for use communally are removed from bathroom areas. 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 Holt DS0000021052.V262859.R01.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 Holt DS0000021052.V262859.R01.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): 1,2,3 & 6 There is a need for the Home to update its Service User Guide to ensure that all service users are aware of information relating to the home. The home has a good process for assessing prospective new service users. EVIDENCE: The Service User Guide is provided to all new and existing service users. It does however require some minor updating e.g. a copy of the revised complaints procedure will need to be attached and the name change of CSCI from NCSC will need to be reflected. The Service user Contracts in place have been updated since the last inspection, therefore the previous inspection requirement has now been met. Records inspected showed that Pre admission assessments are carried out on all new and potential service users. However, the assessments viewed for the last service users entering the home had not been signed although they had been dated. The home also obtains a copy of a care management assessment from a placing authority where this exists. Intermediate care is not offered. Birch Holt DS0000021052.V262859.R01.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): 7,8,9 & 10 The system for reviewing service users individual care plans is currently requires some improvement, in order to provide consistency in documenting individual’s needs. The home has made limited progress in improving the recording of Controlled Drugs entering the home and being administered, these shortfalls potentially place both service users and staff at risk of error. Service users are treated with privacy and dignity. EVIDENCE: Individual service users care plans were sampled and it was noted that some, but not all, are reviewed on a monthly basis. It was also evidenced that where service users are unable to sign their care plans this is not currently documented. Care plans are made up of short term and long term goals. There is a need for the home to ensure that short-term goal care plans are signed by the person who completes the form. The health needs of service users are well met with evidence of good multi disciplinary working taking place, on an as required basis. Staff said that Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 10 where possible service users retain contact with professionals such as dentists, opticians and chiropodists whom they had visited before coming to the home. Records of drug administration are fully kept, although some clarification is required of the codes used for drugs that are not administered. The home has a Controlled Drug Book in place, however this details the name of the drug, the date it was received from the chemist and the name of the service user it is prescribed for. It is recommended that this book should be used as a means of daily recording controlled drugs being administered and should be quality audited on a regular basis. Personal support in the home is offered in such a way as to promote and protect service users privacy and dignity, whilst promoting their independence. Service users informed the inspector that they are treated with dignity and that their privacy is respected at all times. Birch Holt DS0000021052.V262859.R01.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): 12,13 & 15 Social activities are well managed with service users choosing what they would like to attend. The home is good at encouraging service users to attend Community events. Meals provide daily interest and variation for people living at the home. EVIDENCE: Staff told the inspector that service users are free to go to bed and rise at a time of their own choosing. Service user activities are arranged and can be altered according to service users requests. Service users are free to participate in activities, held by the home or within the local community, or not as they wish. The home has well established links to local community events and activities. Staff said that service users are actively encouraged to maintain family contact and that visitors could attend the home at any time and in accordance with the service users wishes. Service users said that they enjoy the food served in the home and that alternative choices are available if they do not like the days menu. Service users may have guests to stay for a meal at any time. The home’s Care Manager said that medical or therapeutic diets are provided as needed. The meal served during the inspection was ample in quantity and attractively presented. Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 12 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 home has a complaints procedure that requires amending in order to meet the Standard and relevant regulation. The homes procedures, processes and training of staff should protect service users in the event of any allegation of abuse. EVIDENCE: The homes current complaints procedure is somewhat unclear and requires reviewing in order to meet the relevant Standard. The complaints procedure currently states that the CSCI can only be contacted if the complaint has not been satisfactorily resolved by the home. Therefore, the complaints procedure will require amending to detail that the CSCI can be contacted at any time in the event of a complaint. The home has received no complaints in the last twelve months. The Care Manager said that staff had completed training in the protection of vulnerable adults within the last year. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. This was evident from the staff files that were viewed. The home’s Care and Deputy Manager were aware of the procedures to follow in the event of an adult protection issue. Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 13 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): 19,22,24,25 & 26 The home provides a good quality of accommodation. Communal areas and bedrooms are maintained to a good standard, providing pleasant accommodation. EVIDENCE: The location and layout of the home are suitable for its stated purpose. The home is well maintained and all areas of the home, including the garden, are accessible to service users. The home has an ongoing plan of refurbishment in place. The Care Manager said that should a service user require aids or specialist equipment, an Occupational Therapist would assess the home. Service users bedrooms are pleasantly decorated. Service users are actively encouraged to bring in their own possessions and personalise their bedrooms. The Care Manager said that radiator guards would be fitted to radiators where required and that risk assessments are in place, which are reviewed regularly. Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 14 The home was clean and odour free throughout. An effective infection control procedure is in operation in the home. Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 15 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 A competent staff team meets the service users needs. The home has a commitment to its staff achieving National Vocational Qualification (NVQ) level two and the recommended 50 has been met. Staff are trained to do their jobs. The home has made some improvement in obtaining all items required for staff recruitment files, however, the previous inspection requirement relating to staff file remains unmet. EVIDENCE: Either of the two Registered Managers attends the home on a daily basis. There are a manager, four carers, a cleaner and a cook on duty for the morning and early afternoon. From the early afternoon until early evening this number is reduced to a manager and two carers. From 6pm there are three carers to assist service users with retiring to bed. This number is then reduced to two night carers. There is a staff rota in place, which was made available to the inspector at the time of the inspection. Service users aid that there are enough staff to met their needs. They said that they find staff to be helpful and pleasant. The home currently has six care staff trained to NVQ level two, with a further four staff undertaking NVQ level three. The home also has two staff trained to NVQ level four. Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 16 Staff recruitment files were viewed and it was evident that not all items required under Standard 29 are currently obtained by the home e.g. proof of identity, recent photograph and two references. Staff training records showed that over the last twelve months the home had provided a range of training, including fire training, health and safety, food hygiene and first aid. The home is currently in the process of arranging training in manual handling. The homes induction training package was inspected and was found to be thorough in content. Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 17 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 Registered Managers, the Care Manager and Deputy Care Manager are competent and experienced to run the home and meet its stated purpose. Effective Quality Assurance procedures are in place and appropriate action is taken to address issues highlighted by responses received by the home. Urgent action was required to ensure that all Control of Substances Hazardous to Health (C.O.S.H.H) products are kept in a locked cupboard, that all cupboards labelled ‘keep shut and locked’ are locked at all times when not in use and that all products such as talcum powder and shampoo are clearly labelled with the residents name and any products which could be deemed as for use communally are removed from bathroom areas. Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 18 EVIDENCE: The homes Care Manager has completed NVQ level four and has many years relevant experience in caring for older people. The Care Manager is currently in the process of applying to the CSCI to become the home’s Registered Manager. Quality Assurance questionnaires were given to all service users and visitors to the home in February 2005. The results were published and made available for all to see. It was evident that the home has taken the necessary actions to address any issues raised. Records were also viewed for the half yearly staff and service user meetings that are held. The Registered Manager is an appointee for two service users, all other service users have family or representatives who maintain and safeguard their finances. The home’s maintenance files were viewed and it was evident that fire drills, fire alarm testing, emergency lighting testing and water checks are carried out on a regular basis. From the records viewed it was evidenced that Portable appliance testing had not been completed since 2003. It was pleasing to note that issues raised during the homes recent Health and Safety Inspection are already being addressed by the home. Immediate requirements were made at the time of the inspection as it was noted that potential risks to both service users and staff were apparent. Unnamed products such as talcum powder and shampoo had been left in the upstairs bathroom. The inspector discussed with the Care Manager the risk this could pose to service users if such products were deemed as for use communally. It was also evidenced that air freshener had been left in the upstairs bathroom. The cupboard where the home’s boiler is located, which is clearly labelled ‘keep shut and locked’, was found to be open at the time of the inspection. It was also noted that the downstairs cleaning cupboard where C.O.S.H.H products were stored. Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 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 2 17 X 18 3 3 X X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 20 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 OP1 Regulation 5 (1)(2) Requirement That the Service Users Guide is updated to include the amended Complaints procedure and the NCSC’s name is changed to reflect that it is now known as the CSCI. That where it is impracticable for service users to sign their own care plan, this is documented. That service users care plans are reviewed on a monthly basis. That the Controlled Drug Book is utilised as a daily record of controlled medications administered and that it is audited and quality checked. That the Complaints Procedure is amended to include that the CSCI can be contacted at any time in the event of a Complaint. That recruitment of staff must comply with the Care Homes Regulations 2001 (Outstanding from previous Inspection). That Portable Appliance Testing (PAT) is carried out. That all COSHH products are kept in a locked cupboard. This is an immediate requirement. DS0000021052.V262859.R01.S.doc Timescale for action 01/01/06 2 3 4 OP7 OP7 OP9 15 (2)(c) 15 (2)(b) 13 (2) 01/12/05 01/12/05 01/12/05 5 OP16 22 (7)(a) (b) 19(1)(a) (i)&Sc 2(1-6) 12 (1)(a) 12 (1)(a) 01/12/05 6 OP29 01/12/05 7 8 OP38 OP38 01/12/05 01/11/05 Birch Holt Version 5.0 Page 21 9 OP38 12 (1)(a) 10 OP38 12 (1)(a) That the home’s boiler cupboard is kept locked at all times when not in use. This is an immediate requirement. That all products such as talcum powder and shampoo are clearly labelled with the residents name and any products which could be deemed as for use communally are removed from bathroom areas. This is an immediate requirement. 01/11/05 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP2 OP7 OP9 OP31 Good Practice Recommendations That pre admission assessment records are singed by the person completing the assessment. That short term care plans are signed by the person completing them. That a list of medication omission codes is made available to all medication trained staff. That the arrangements for the management of the home should be reviewed and an application made to the CSCI for the care manager to be registered (Outstanding from previous Inspection). Birch Holt DS0000021052.V262859.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Holt DS0000021052.V262859.R01.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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