CARE HOMES FOR OLDER PEOPLE
Birch Holt Marlpits Lane Ninfield East Sussex TN33 9LD Lead Inspector
Elaine Green Key Unannounced Inspection 10:00 17th October 2006 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.V295523.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 Holt DS0000021052.V295523.R01.S.doc Version 5.2 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 Mrs Anne Heathcote Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 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 older people aged sixty-five (65) years or over on admission 26th January 2006 Date of last inspection 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. The fees charged range from £350 - £395 per week. A copy of the latest Inspection report is available from the home upon request. Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. As part of the unannounced Inspection of Birch Holt a site visit took place to the home on the afternoon of. As part of the Inspection the Registered Manager completed a Pre Inspection Questionnaire that provides the Inspector with statistical information relating to the home. Residents of Birch Holt were also given the opportunity to complete surveys and return them to the Inspector. On the day of the site visit, issues relating to the day-to-day running of the home were discussed with the deputy manager as the Registered manager was not available. Discussions also took place with 6 residents and four members of staff. A range of documents were examined including four residents care plans, four recruitment files, a selection of the homes’ policies and procedures and some of the homes’ daily records. What the service does well:
Birch Holt has a Service User Guide and a Statement of Purpose both of which are available to prospective residents of the home to help them make an informed decision about whether or not to reside there. This home provides a homely clean and welcoming environment for residents to live in. There is ample communal space and a choice of 3 lounges for residents to use for socialising or entertaining guests. The home is well maintained and in good decorative order throughout. The gardens are also well maintained and there is seating on a patio with level access. The food provided in the home is homemade and of good quality. Of 5 comment cards received by the Inspector from residents 3 said they were usually happy with the food and 2 that they always were. The dining room is pleasantly decorated and mealtimes are relaxed. Residents of the home have the opportunity to access local luncheon clubs and participate in a weekly exercise class arranged by the home. The staff are friendly and the residents spoke highly of them.. One resident wrote ‘All the carers are very kind and supportive’ ‘…they always listen to any problems and call my daughter and or the doctor if needed ano Residents spoke highly of the staff and said they were very caring. One residents’ daughter stated that ‘My mother is very weell looked after’ ‘I cannot express how helful and friendly all the staff are to her.’ Staff have the opportunity to participate in training appropriate to the tasks they have to perform in the home and undergo an induction when they begin work at the home. The acting manager and deputy manager are experienced hold the relevant qualifications. The proprietors, although not now responsible for the day-today running of the home, visit the home on a regular, if not, daily basis. The
Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 6 management of the home give out customer satisfaction surveys to the residents of the home on a regular basis to establish their views in relation to the running of the home. What has improved since the last inspection? What they could do better:
The home needs to make improvements in relation to its’ admissions policies and procedures. The preadmission assessments of prospective residents must be more detailed, cover all aspects of an individuals’ care needs and specify their preferences. The assessments should be signed and dated by both the individual being assessed and the assessor. Once the assessment is completed the home must confirm in writing that they are able to meet the prospective residents’ needs prior to admission. In addition to this the prospective resident must also receive a copy of the Service Users’ Guide, Statement of Purpose and a costed copy of their Contract/Statement of Terms and Conditions prior to moving in to the home. The home should not admit people who are out of their registration category e.g. who are suffering from dementia. Where this has already happened the home must ensure that they can clearly demonstrate through the assessment and care planning processes that they are able to meet the individuals’ needs and that the care plan and associated risk assessments are reviewed on a regular basis. Once an individual has moved into the home a care plan must be drawn up with the resident and this should be signed and dated by both the manager and resident. The care plan must be based on a robust assessment including all the required risk assessments and be reviewed as and when required as well as on a monthly basis. The medication practices adopted by the home are unsafe and a referral has been made for a pharmacist from the Commission for Social Care Inspection (CSCI) to visit the home and undertake an inspection. The home routinely dispenses medication into cassettes a week in advance and this is not considered to be good or safe practice. There are no guidelines in place for when PRN or ‘as and when medication’ can be administered. Some of the medication that was examined was out of date, some had no name on and some was no longer required so should have been disposed of. There is no signature sheet so it is impossible to establish who has signed for medication and not all the medication administration sheets had not been completed as required. Consultation should take place with residents with respect of their preferences in relation to the arrangements for the provision of food at meal times. This consultation should take place on an individual basis and not just at residents’ meetings as some individuals may not feel comfortable speaking up in a group
Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 7 setting. Consultation should also take place with residents in respect of the activities that they would like to be included in the homes’ activity programme. Once consultation has taken place then the results of the consultation should be published and made available to the residents. The home must provide a varied and appropriate activity programme based on consultation and the relevant assessments of service users. When new care staff are employed they must not be deployed to work in the home until all the required identity and security checks have been satisfactorily completed. Satisfactory security checks had not yet been received for one of the staff working in the home on the day of the site visit so an immediate requirement was made that no person shall work in the home prior to the PoVA first check being received. The references sought in relation to new staff must be appropriate and one must be form the last or current employer. Any gaps in employment must be accounted for. New staff must not work unsupervised until they have completed both the ‘in house’ induction and the ‘skills for care’ induction. Both inductions must be documented and be available for Inspection. All staff must complete the mandatory training within the required timescales and the home must work towards ensuring the a minimum of 50 of the care staff they employ obtain a National Vocational Qualification (NVQ) in Care at Level 2 or above. At the last Inspection it was required that clarification of the roles and responsibilities of the owners/managers and the Care Manager (acting manager) and the relevant qualifications each has, was sent to the Commission for Social care Inspection (CSCI). This has not been received, however there are plans for the Care Manager (acting manager), who is appropriately experienced, to apply in the near future. The home does not have a registered manager in day-to-day charge of the home and as such the CSCI will be issuing a new certificate stating that the post is vacant. The providers have not been undertaking the monthly-unannounced visits to the home or providing the CSCI and acting manager with reports in relation to the findings at these visits. This is a requirement that is outstanding from the last 2 inspections. It is important that these visits take place and that the providers take steps to ensure that action is taken to make improvements in any of the areas that they identify shortfalls in. It is important that the results of residents’ surveys are published and made available to the residents of the home as is required so it is possible to establish whether or not anything has changed as a result of the survey taking place. The night staff are using one book to record information about all the residents in the home. This is considered to be poor practice, as it does not protect residents’ dignity and privacy. The manager must ensure a new system or recording this information is introduced and the method used by the day staff is perfectly acceptable. When accidents and incidents in the home are documented the manager must ensure that all the action taken as a result of an accident should be
Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 8 documented including whether or not risk assessments and care plans have been reviewed and updated. The home needs to obtain a copy of the new guidelines from the environmental health in respect of food hygiene and the records that they now require care homes to keep. In general the home is not undertaking all the risk assessments that they should be e.g. access to balconies, security of the home in relation to individuals’ vulnerability and assessing individuals’ risk of falling. Other concerns in relation to shortfalls identified in respect of residents’ health and safety are specified in the report. 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.V295523.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to admission but are not provided with all the documented information they require to make an informed decision about whether or not to reside there prior to admission. EVIDENCE: Although Birch Holt has a Statement of Purpose and a Service User Guide and service users have a Contract/Terms and Conditions these are not always provided to prospective service users prior to their admission to the home. Some residents said that they had recently been given a copy of the Service User Guide but due to a change in legislation all residents must be provided with a copy of their Terms and Conditions which must be costed and specify what is included in the fees. Preadmission assessment documentation was examined. Preadmission assessments are undertaken by the manager or deputy manager prior to prospective residents being admitted. However, the documentation relating to this process is not sufficiently detailed in respect of covering all the areas that
Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 11 need to be assessed. Further information is needed in relation to specifying what support the individual is currently receiving, how and where the assessments were carried out and who was involved with the assessment process. This documentation should be signed by both the assessor and the individual being assessed or their representative. The home has obtained copies of social services assessments where possible but this information had not been transfered onto the homes’ own pre admission documetaion or onto the care plans that were examined. In the future, once they have been assessed, the home must inform prospective service users needs in writing of whether or not they are able to meet thier. Service users are able to visit the home to look round, and the first months’ stay is on a trial basis. Two service users confirmed that they were able to visit and test drive the home before making a decision about whether or not to reside there. One service user has been admitted to the home who is suffering from a dementia type illness. This home is not registered to admit people suffering from this type of illnes however, this person may continue to reside in the home porvided that the home demonstrates that they are able to meet this persons needs. This will include providing specific and clear guidance through the assessement and care planning processes, holding regular reviews and providing staff with the specialist training required in order for them to support this person appropriately. Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users care plans do not provide the guidance required for staff to support service users in their daily lives and their social care needs are not being met. Service users heatlh care needs are being met but the medication administration procedures adopted by the home are unsafe. EVIDENCE: The four care plans that were examined on the day of the site visit had not been based on full and robust assessments that specified service users’ preferences. The information they contain is scant and there was no evidence that they had been written in consultation with the service users. Specific guidance was missing e.g. one care plan states that assistance is needed for an individual to bathe but it does not specify what this assistance is. Another person is diagnosed as sufffering from a demetia type illness but there was no mention of this in the care plan and there were no specific guiedlines in relation to how this person was to be supported to manage their illness and behaviours. The assessment for another person states that they present with challenging or unacceptable behaviour but there is no care plan in place to provide staff with guidance for how to deal with this individual or of what signs
Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 13 to look out for. There are no asessments or care plans in place for social activities. One indivual had had a fall and an accident report had been completed but there was no evidencce of any reassessment taking place in relation to their mobility or safety and there was no record of their falls history. The environmental risk assessments in relation to what areas of the home and grounds individuals had access to or of whether or not they needed assistance were mising and there was no evidence individuals being assessd in relation to their vulnerability and the security of the home. Medication records and medication stores were examined and the staff on duty explained the procedures they follow when they dispense medication. The home routinely dispenses a weeks worth of medication into cassettes for each resident. They also routintely pot up soluble asparin into named medication pots on a weekly basis. The practice of dispensing medication and ‘potting it up’ in this way is unsafe and a referal has beeen made for the home to be visited by one of the CSCI’s Pharmacists. In addition to this there was no signature sheet with the mediation administration records so it was impossible to establish who had signed for medication, there were gaps were medication had not been signed for and there were no guidelines in place for when PRN or ‘as and when’ medcation should be administered. In the medication store some of the medication found was out of date and there were homely remedies with no name on and for which there were no guidelines in place. There was also medication that albeit was still in date, had not been used for a long time, was no longer required and should have been disposed of. Medication must not be ‘potted up’ in advance and an immediate requirement was made on the day of the site visit to this affect. Discussions with the deputy manager, 2 residents and the examination of care plans and other supporting documentation confirmed that appropriate health care referals are made when required. Residents stated that they see health care professionals in the privacy of their own rooms. One resident wrote ‘All the carers are very kind and supportive’ ‘…they always listen to any problems and call my daughter and or the doctor if needed.’ Another individual was returning to the home from hospital and although the reassessment was not available for examination the deputy manager assured the Inspector that a reassessment had been undertaken in respect of any change in the indidviduals’ needs earlier in the week. Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is little provision for service users to participate in appropriate social and leisure activities. The food provided is wholesome and nutritious. EVIDENCE: The home does not provide service users the opportunity to participate in varied appropriate, enjoyable and stimulating activities on a regular basis. Four service users stated on the day of the site visit that they were not happy with the activities on offer or the frequency of them and two said they were often bored. Feedback from comment cards included ‘sometimes there are activities usually once a week.’ ‘Sometimes activities are arranged by the home’ and ‘Sometimes activities are organised in the home- keep fit classess - maybe occassional supervised trips out would be nice’. Examination of records and discussions with staff confirmed that the only organised activity on offer at the home on a regular basis is a weekly exercise session. There are photographs on the wall in the hallway from activities that have taken place in the past one from a meal out last year and one from an outing earlier this year residents stated they had enjoyed these activities. There are jigsaws and games in the lounge area for residents to use and some books for them to read. Staff stated that some residents enjoy attending local luncheon clubs and others attend a local church. The deputy manager explained that some activities have been
Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 15 tried but have been unsuccesful but here was no documentary evidence to support this. An examination of records in relation to the day to day running of the home confirmed that there was little in the way of structured activities being offered on a regular basis. All residents should be consulted with about the programme of activities arranged by or on the behalf of the home, and activities should be provided in relation to recreation, fitness and training. The Inspector joined the residents of the hoime for their midday meal. This was hot, homemade and well presented. On the day of the site visit service users stated that they enjoyed the food and of the 5 comment cards returned; 3 indicated that they usually like the meals and 2 that they always did. Several people stated on the day of the site visit that they felt it was a long wait between breakfast and the midday meal. It was noted that staff supported those residents that needed help with their meal an appropriate, dignified and timely manner. Although on the day of the site visit, the tables were laid formally it was disappointing to note that no choice was offered for the main course or sweet and there was no menu on display. Three people stated during the midday meal that they are not involved in the writing of the menus however the deputy manager explained that residents are often asked if there is anything they wish to have on the menu during residents’ meetings. It is recommended that in addition to the residents’ meetings, consultation takes place with residents on an individual basis. This should be in respect of personal preferences for the arrangements for the provision of food at meal times (including times of meals) and personal preferences in relation to the food they would like on the menu. All records in relation to consultation should be documented and be available for Inspection. Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the homes’ adult protection and policies and procedures, and service users feel they are listened to. EVIDENCE: The homes’ complaints policies and procedures are satisfactory and service users stated that they are confident in approaching the management if they had any complaints. Service users surveys also indicate this, all 5 of the comment cards returned stated that they knew who to go to make a complaint. The home has a copy of the local adult protection policies, procedures and guidelines and the homes’ policies and procedures in relation to raising an adult protection alert have been updated as required at the last Inspection. The home provides staff with the appropriate training in recognising abuse Birch Holt DS0000021052.V295523.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25,26. 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, homely, safe, well maintained and clean environment for service users to reside in. EVIDENCE: The Inspector had a tour of the building on the day of the site visit. Birch Holt provides a homely environment for the service users resident in the home. The home is bright clean and hygienic. Service users were observed using the main lounge to spend time with each other and watch television. This area is large and has a range of comfortable armchairs, television, books, games and jigsaws. This room leads onto the dining room that looks out over gardens at the side of the property. There is also a small communal room that contains a pleasant seating area on the ground floor that looks out over the gardens to the rear of the home. There is a patio and seating area to the side of the property and staff stated many service users enjoy sitting in this area, as it is sheltered. On the first floor there is another large lounge that contains a range of comfortable seating, a television and one of the residents’ piano. There are
Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 18 patio doors from this lounge leading onto a balcony with open railings looking over the back garden and far reaching views to the countryside. The Inspector was invited to see some of the residents’ bedrooms and these are personalised and meet their needs. Some service users have brought their own furniture and others have chosen to use those provided by the home. Two of the bedrooms on the ground floor nearest the kitchen felt cold, these rooms have different type of heating and staff stated that they often use additional heating for these rooms. It was noted that despite the temperature dropping quite considerably that evening this heating was not brought in while the Inspector was there. Birch Holt DS0000021052.V295523.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the numbers and skills of the staff employed by the home. The recuitment procedures adopted by the home are not safe. Not all staff hold the relevant qualifications. EVIDENCE: Feedback from the 5 comment cards received from people who live in the home all indicated that there are usually enough staff on duty and that usually staff answer the call bell promptly. On the day of the site visit there appeared to be enough staff on duty a in addition to the care staff there was also a cleaner and a cook. The home does not employ an activities organiser and as already stated there are not many activities provided in the home. The current staffing levels are such that it would be difficult for care staff to facilitate activities when also attending to the care needs of the residents. The recruitment files were examined for the 4 members of staff including the most recently recruited. None of the 4 files contained all the required information in respect of identity and security checks. The records for 3 staff members showed that although the home had now received satisfactory security checks for them, they had been deployed to work in the home some 2 months before they had received confirmation that the checks were clear. In addition to this the home had employed another individual prior to their security checks being completed and they were found to be working in the home on the day of the site visit. An immediate requirement was made that no
Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 20 person shall work in the home prior to the PoVA first check being received. The home has assured the Inspector that this person did not work in the home again until these checks were received. Shortfalls were also identified in relation to Identity and references. In one of the recruitment files the capacity in which the referees knew the staff member was not specified, in another only one reference had been supplied and this was not their previous employer. One file had no proof of identity and another the gaps in employment were not accounted for. The deputy manager stated that new staff usually completed a formal induction within the first 12 weeks and that they were aware of the new changes to the induction. New staff are now required to complete the ‘Common Induction Standards’ within the first 12 weeks of employment and must not work unsupervised until this is completed. Unfortunately she was unable to produce one for examination on the day of the Inspection so the quality of this was impossible to assess. The deputy manager also stated that both herself and the manager supervise all staff formally and on a one to one basis while working on the floor. Training files were examined and confirmed that some staff had completed the mandatory training but not all and it was unclear when further training was due. The home has not yet met the target for 50 of the staff team to hold a National Vocational Qualification (NVQ) in Care at Level 2 or above. Residents spoke highly of the staff and said they were very caring. One residents’ daughter stated that ‘My mother is very weell looked after’ ‘I cannot express how helful and friendly all the staff are to her.’ Birch Holt DS0000021052.V295523.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager is appropriately experienced. The health, safety and welfare of service users and staff is protected and promoted to some extent however the shortfalls identified have the potential to place service users at risk. EVIDENCE: At the last Inspection it was required that clarification of the roles and responsibilities of the owners/managers and the Care Manager (acting manager) and the relevant qualifications each has, was sent to the CSCI. This has not been received, however there are plans for the Care Manager (acting manager), who is appropriately experienced, to apply in the near future. The home does not have a registered manager in day-to-day charge of the home and as such the CSCI will be issuing a new certificate stating that the post is vacant.
Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 22 The providers have not been undertaking the monthly-unannounced visits to the home or providing the CSCI and acting manager with reports in relation to the findings at these visits. This is a requirement that is outstanding from the last 2 inspections. It is important that these visits take place and that the providers take steps to ensure that action is taken to make improvements in any of the areas that they identify shortfalls in. The home gives out a short survey for residents to complete every three months. Although the same surveys are available for families and other visitors to complete visitors, families, healthcare and social care workers are not asked to complete a survey designed specifically for them. The results of the residents’ surveys are not published or made available to the residents of the home as is required so it is impossible to establish what the results were and whether or not anything has changed as a result of the survey taking place. It is recommended that the surveys given at 3-month intervals should vary so that interest is not lost and the exercise does not become routine. The providers have ensured that the CSCI is informed of events in the home in line with regulation 37 of the Care Standards Act in respect of hospital admissions etc. The records that were examined were not all accurate complete and up to date e.g. medication administration guidelines missing and care plans incomplete and not up to date. In addition to this the night staff are using one book to record information about all the residents in the home. This is considered to be poor practice, as it does not protect residents’ dignity and privacy. It is required that a different system is adopted by the home for the night staff to use. The method used by the day staff is perfectly acceptable. In respect of health and safety of residents and staff in the home the Inspector had mixed findings, some of which are concerning. Accidents and incident in the home are documented and the action taken in respect of any treatment is recorded however, it is required that all action taken as a result of an accident should be documented including whether or not risk assessments and care plans have been reviewed and updated. A record of accident reports must also be kept on the residents’ care plan. The temperature of cooked food is being recorded however; the home needs to obtain a copy of the new guidelines from the environmental health in respect of food hygiene and the records that they now require care homes to keep. During the tour of the home it was noted that residents’ bedrooms had call bells but the lavatory on the first floor one on the ground floor did not. Not all rooms had window restrictors fitted and there was no risk assessment in place in respect of residents’ when accessing the balconies leading off the 1st floor lounge and 2 of the residents’ rooms. Fire doors, including the kitchen door, were wedged open. The water temperatures from hot water outlets were tested but not on a monthly basis as are required. The chair lift had not been service since 2001. None of the electrical equipment had stickers on to show that it had had a Portable Electrical Test. It was cold in 2 of the bedrooms and in the lounge. There
Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 23 appeared to be little or no security arrangements in place in respect of monitoring whether or not residents had left the home and this had not been risk assessed. Although risk assessments take place on a monthly basis in respect of each of the residents’ rooms, as already stated environmental risk assessments are not in place for the areas of the home and grounds that residents can access and the areas that are restricted are not specified. Recruitment practices are poor and have the potential to place residents at risk. Medication procedures are poor and also have the potential to place residents at risk. Care plans do not provide the guidance required to ensure that residents’ health and safety is protected and promoted at all times. The homes’ insurance certificate is up to date. Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 24 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 2 2 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 2 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 X 2 1 Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 25 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 OP2 Regulation 2(1,2,3bb ,bc,bd) Timescale for action That all prospective service users 30/12/06 are provided with a copy of the homes, statement of purpose, service user guide and a costed contract/statement of terms and conditions prior to moving into the home. All service users currently residing in the home should also be given an up to date copy of this information. That preadmission assessments 30/11/06 must be robust and assess all areas required by schedule 3 and 4. All documentation must be signed and dated and confirmation must be given in writing specifying whether the home can meet the assessed needs of the prospective service user prior to them moving into the home. The home must only accommodate service users’ whose needs they can meet That care plans are based on 30/12/06 robust assessments, that they are drawn up with the service user, signed, dated reviewed on a regular basis and as and when required.
DS0000021052.V295523.R01.S.doc Version 5.2 Page 26 Requirement 2 OP4 OP3 12(1ab) 14(1abcd 2ab) 3 OP7 15(1,2bcd ) Birch Holt 4 OP9 13(2) 5 OP12 16(2mn) 6 7 OP25 23(2p) 18(1abc) OP28 8 OP29 19(1abc) Sch 2 9 OP30 12(1ab) 18(1abc) 10 OP31 9(1,2) Medication must not be ‘potted up’ in advance. An immediate requirement was made on the day of the site visit. Referral made for the CSCIs’ pharmacist to Inspect the home. The home must consult with service users in respect of their preferred activities and provide an activities programme that based on robust assessments and reflects residents’ preferences. That service users’ own rooms are maintained at a reasonable temperature. That a minimum of 50 of the care staff employed by the home hold an NVQ in Care at Level 2 or above. An immediate requirement was made on the day of the site visit that no person shall work in the home prior to the PoVA first check being received. The home must ensure all the required identity and security checks are completed prior to them being deployed to work in the home. That the ‘in house’ induction is documented and that prior to working unsupervised in the home and within the first 12 weeks of employment all new staff complete a formal documented ‘Common Induction Standards’. That all staff complete the mandatory training within the required timescales and that specialist training is provided to enable staff to meet the specific care needs of the service users resident in the home. That the arrangements for the management of the home should be reviewed and an application made to the CSCI for the care
DS0000021052.V295523.R01.S.doc 16/10/06 30/01/07 30/11/06 30/03/07 30/11/06 28/02/07 30/12/06 Birch Holt Version 5.2 Page 27 11 OP33 26 12 OP38 12(1ab) 13(4abc) 17(1a) Sch 3 23(4ac(i)) 16(j) manager to be registered Outstanding from previous Inspection timescale 26/02/06 not met That monthly Regulation 26 30/12/06 visits are carried out by the Registered Providers and a report sent to the CSCI, in accordance with this regulation. Out standing from the last Inspection timescale 26/02/06 not met. That service users health and 30/12/06 safety is protected and promoted at all times. That the risk assessments specified in the report are completed and that the shortfalls identified within the report in respect of health and safety are addressed. An immediate requirement was made on the day of site visit for door wedges to be removed from all fire doors. 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. Refer to Standard OP15 Good Practice Recommendations That service users are consulted with on an individual basis regarding their preferences in relation to the arrangements for the provision of food at meal times. Birch Holt DS0000021052.V295523.R01.S.doc Version 5.2 Page 28 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
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