CARE HOMES FOR OLDER PEOPLE
Birch Holt Marlpits Lane Ninfield East Sussex TN33 9LD Lead Inspector
Rebecca Shewan Unannounced Inspection 26th January 2006 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.V274298.R01.S.doc Version 5.1 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.V274298.R01.S.doc Version 5.1 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.V274298.R01.S.doc Version 5.1 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 1st November 2005 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. Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second unannounced inspection to take place in the CSCI inspection year of 2005/2006. To gain a complete overview of the standards assessed it will be necessary to read both inspection reports for this inspection year. This unannounced inspection took place during the morning of the twenty sixth of January 2006. Before the inspection papers held by the Commission for Social Care Inspection were read. The inspection of the home took two and three quarter hours. A short tour of the premises and the Care Manager and the Deputy Manager were spoken with. There were twenty-six service users (known as Residents) living at the home at the time of the inspection. What the service does well: What has improved since the last inspection?
Following the inspection of Birch Holt, conducted on first November 2005, the home has addressed any issues raised by the residents in their responses in the CSCI Service Users Comment Cards left at the home at the time of the inspection. The home has also conducted its own quality review since November and the published results have been made available to all. From the documentation viewed, the tour of the premises and discussions with the Care Manager and her Deputy, it was evidenced that the home has made improvements to ensure that the previous inspection requirements; 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
Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 Page 6 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, that Portable Appliance Testing (PAT) is carried out, that all Control Of Substances Hazardous to Health (C.O.S.H.H) products are kept in a locked cupboard, that the home’s boiler cupboard is kept 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, have been met in full. The home has also made improvements to ensure that the following recommendations; that pre admission assessment records are signed by the person completing the assessment, that short term care plans are signed by the person completing them and that a list of medication omission codes is made available to all medication trained staff, have been met in full. 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 Holt DS0000021052.V274298.R01.S.doc Version 5.1 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.V274298.R01.S.doc Version 5.1 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): 1,2,4 & 5 The home has suitable procedures in place for allowing potential new residents with the opportunity to visit the home. EVIDENCE: The Service Users Guide was viewed and it was evidenced that the previous inspection 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, has now been met in full. Pre-admission assessments were viewed and it was evidenced that the previous inspection recommendation, that pre-admission assessment records are signed by the person completing the assessment, has now been met in full. Staff were observed to have the appropriate skills and experience to deliver the services and care, which the home offers. The Care Manager said that potential new residents are invited to stay at the home for a day and have a meal with the current residents. Trial periods of two to four weeks are offered to all potential new residents as a matter of
Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 Page 9 course. The Care Manager said that the trial period could be extended if required and with the agreement of all parties involved. Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 & 11 Resident’s dying/critical illness wishes are recorded in their care plan and staff are aware of residents choice in relation to this matter. EVIDENCE: From Care plans viewed it was evidenced that the previous inspection requirement that the previous inspection requirements that where it is impracticable for service users to sign their own care plan, this is documented and that service users care plans are reviewed on a monthly basis, has now been met in full. It was also evidenced that the previous inspection recommendation that short-term care plans are signed by the person completing them, has also been met in full. The Controlled Drug register was viewed and it was evidenced the previous inspection requirement, that the Controlled Drug Book is utilised as a daily record of controlled medications administered and that it is audited and quality checked, has now been met in full. The Medication Administration Record (MAR) sheets were viewed, omission of medication codes have been implemented, therefore the previous inspection recommendation that a list of medication omission codes is made available to all medication trained staff, has now been met in full.
Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 Page 11 From the care files viewed it was evidenced that the home records resident’s wishes in the event of dying or critical illness. The Care Manager said that resident’s wishes to remain at the home would be respected until such time that the home is unable to meet the needs of the resident. If necessary the input and assistance of the District Nurse would be utilised, in order for a dying resident to remain at the home. Resident’s relatives are able to remain with the resident and in accordance with the resident’s wishes. Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 Page 12 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): 14 Residents are encouraged to have control over their lives and to exercise choice. EVIDENCE: The home is run to ensure that the resident’s are encouraged to maintain their independence in making choices and decisions relating to their daily living. Any information relating to resident choice or decision-making is recorded in the resident’s care plan. Residents are encouraged to remain independent and those who are able attend the local community at a level of their choosing. Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 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): 16 & 17 Resident’s legal and political rights are protected and respected at all times. EVIDENCE: The home’s Complaints Procedure was viewed and it was evidenced that the previous inspection requirement, that the Complaints Procedure is amended to include that the CSCI can be contacted at any time in the event of a Complaint, has now been met in full. Residents vote by proxy and both the Care Manager and Deputy Care Manager said, that if a resident wished to attend the polling station then they would be encouraged to do so. The Care Manager said that most residents have family or a representative to ensure that their legal rights are protected. Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 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): 20,21 & 23 The home as good facilities in place for residents to maintain their personal hygiene, both independently and with assistance. Resident bedrooms were comfortable and residents are encouraged to have their personal possessions around them. EVIDENCE: There are three communal lounge areas within the home; two located on the ground floor, one of which is utilised as the main lounge and one which is utilised as a quiet lounge and the third lounge being located on the first floor. The Care Manager said that resident’s make good use of all lounge areas. The home has a well-maintained garden, which is accessible to all. There are ample toilet and bathroom facilities for residents. Thirteen bedrooms have en-suite facilities consisting of a toilet and hand washbasin or a toilet, hand washbasin and bath. There is a bathroom located on each floor, one of which has a specialist bath hoist fitted.
Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 Page 15 Resident’s bedrooms are pleasantly decorated. Residents are actively encouraged to bring in their own possessions and personalise their bedrooms. Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 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): 28 & 29 The home has a commitment to its staff achieving National Vocational Qualification (NVQ) level two. EVIDENCE: The Care Manager said that the home has eight care staff trained to NVQ level two or above. The home hopes to achieve the required 50 of staff trained to NVQ level two by the beginning of next year. The Deputy Care manager said that improvements had been made in ensuring that recruitment of staff must comply with the Care Homes Regulations 2001, staff files viewed confirmed this. Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 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): 31,32,33,36,37 & 38 There is a need for the Registered Providers/Managers to provide the CSCI with some clarification about their ability to manage the home, with regards to qualifications, skills and experience. The homes Registered Providers/Managers are required to carry out monthly Regulation 26 visits and produce a report, which is sent to the CSCI. There is a need for the homes Abuse Guidance Policy to be amended in order that it is consistent with the East Sussex Multi Agency Procedures – Protection of Vulnerable Adults. EVIDENCE: The owners are also the Registered Managers, although there is also a Care Manager who has responsibility for the day-to-day running of the home. There is a need for clarification of the roles and responsibilities of the owners/managers and the Care Manager and the relevant qualifications each
Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 Page 18 has, to meet the Regulations and the standards. Should the current Registered Providers/Managers not have the relevant qualifications i.e. NVQ Level 4 in Care & Management and/or the Registered Managers Award, then these qualifications will need to be obtained or a suitably qualified Manager must be appointed and registered as the homes Registered Manager. During the inspection it was evident that the Care Manager and her Deputy operate an open door policy and are available to residents and staff at any time whilst on duty. The homes Care Manager and staff work in a co-operative manner in order to achieve the aims and objectives of the home. As a result of the discussion held between the Care Manager and the Inspector, regarding the clarity of the management of the home, it was evident that monthly Regulation 26 visits were not being carried out by the Registered Providers/Managers. Therefore there is a need for Regulation 26 visits to be carried out and for a report to be sent to the CSCI, in accordance with this regulation. The Inspector also discussed with the Care Manager that should the Registered Providers/Managers be required to appoint a new Registered Manager, these visits must continue to be completed by the Registered Providers. Six CSCI Service Users Comment Cards were received by the CSCI following the previous inspection of Birch Holt, conducted on first November 2005. It was evidenced that the home has addressed any issues raised by the residents in their responses in the CSCI Service Users Comment Cards and that the home has also conducted it’s own quality review, the results of which have been published and made available to all. Suitable insurances policies and certificates were viewed and found to be on display where appropriate. The Care Manager said that both formal and informal supervision of staff is conducted within the home, records viewed confirmed this. The homes Policies and Procedures file was viewed, with annual reviews of individual policies/procedures evident. However, the homes Abuse Guidance Policy was noted to contain information that conflicts the East Sussex Multi Agency Procedures – Protection of Vulnerable Adults. Therefore a requirement has been made. From the records viewed and from the tour of the premises it was evidenced that the previous inspection requirements, that Portable Appliance Testing (PAT) is carried out, that all C.O.S.H.H products are kept in a locked cupboard, that the home’s boiler cupboard is kept 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, have been met in full. Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 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 X X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X X 3 3 X 3 X X X STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X 3 X 3 3 3 Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 Page 20 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 OP31 Regulation 8(1)b (i)(iii)& 18(1)a Requirement That clarification of the roles and responsibilities of the owners/managers and the Care Manager and the relevant qualifications each has is sent to the CSCI. That monthly Regulation 26 visits are carried out by the Registered Providers and a report sent to the CSCI, in accordance with this regulation. That the homes Abuse Guidance Policy must be amended to be consistent with the East Sussex Multi-Agency Procedures – Protecting Vulnerable Adults. Timescale for action 26/02/06 2 OP33 26 26/02/06 3 OP37 13(6) 26/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP31 Good Practice Recommendations That the arrangements for the management of the home should be reviewed and an application made to the CSCI
DS0000021052.V274298.R01.S.doc Version 5.1 Page 21 Birch Holt for the care manager to be registered (Outstanding from previous Inspection). Birch Holt DS0000021052.V274298.R01.S.doc Version 5.1 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
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