Inspection on 28/08/07 for Birch Holt Retirement Home

This inspection was carried out on 28th August 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Birch Holt Retirement Home 16/10/06

Birch Holt Retirement Home 26/01/06

Birch Holt Retirement Home 01/11/05

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 Retirement Home Marlpits Lane Ninfield Battle East Sussex TN39 5BY Lead Inspector Robert Pettiford Key Unannounced Inspection 9:10 28th and 29th August 2007 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 Retirement Home DS0000021052.V337430.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 Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birch Holt Retirement Home Address Marlpits Lane Ninfield Battle East Sussex TN39 5BY 01424 892352 01424 892352 Brichholt1@yahoo.co.uk 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) Mr Terence Fusco Mrs Anne Heathcote Post Vacant Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of residents to be accommodated is twenty-six (26) Residents must be older people aged sixty-five (65) years or over on admission 25th January 2007 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 decorated and comfortably furnished, for the needs of residents. The garden area is wellmaintained and accessible to residents. The fees charged range from £395 - £415 per week. A copy of the latest Inspection report is available from the home upon request. Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Birch Holt took place over two days the 28th and 29th August 2007. The Inspector present at the inspection agreed and explained the inspection process with the manager present during the inspection. The focus of the inspection was to assess Birch Holt in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older Persons. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The Inspector gained information from a variety of sources including preinspection information such as the previous report and discussion and correspondence with the registered provider in the planning process to ensure hypotheses were formulated to support the inspector to explore any issues of concern and verify practice and service provision. The home had completed an annual quality assurance assessment questionnaire which was received prior to the site visit to the home. This provided the Inspector with information relating to What the home considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. During the inspection, documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other area’s viewed included risk assessments, pre-admission assessments, menus, rota’s, training records and recruitment records. In addition a full environmental tour took place. The Inspector identified three residents for case tracking, speaking with them and assessing the available information held in the home pertaining to the care provision for both. In addition, the Inspector met with the other residents, which gave them a good opportunity to observe the quality of care within the home and activities enjoyed. Several completed comment cards were received from residents which expressed their opinions of the service. The comments received have been included as evidence in making judgements on the service provided. What the service does well: The home offers a homely environment in which to live and staff are caring and friendly. The residents enjoy a good level of organised activities but can also benefit from a one to one session if they prefer. Residents can also benefit from help in opening their private mail if they so wish. Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 6 High emphasis is placed on encouraging the residents to maintain their independence for as long as possible but help is always offered when this is no longer an option. The home works closely with the local PCT and is developing good palliative facilities. The staff group is committed to providing a good service to the residents and works well as a team. Many residents were spoken to and all who were able to do so confirmed that the staff are very caring and kind to them at all times. The inspector noted that staff spoke to the residents in a respectful and courteous manner. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents have all the information they need to make an informed choice about whether they wish to live at the home. Resident can be confident that their needs will be assessed prior to moving in to the home and they have the opportunity for visits prior to committing to living at the home. Intermediate care is not provided EVIDENCE: It was identified at the last inspection that although the home has a Statement of Purpose it was not always provided to the residents and the copy of their terms and conditions did not include all the information. The manager confirmed that this information is provided and the Statement of Purpose Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 9 included all the information as required of Schedule 1 of the Care Home Regulations 2001. Prospective residents are given the opportunity to spend time in the home. An individual member of staff is allocated to give them information, special attention, help them to feel comfortable in their surroundings, and enable them to ask any questions about life in the home. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. The staff management team may consider the application together with other staff, where all information is shared and the views, opinions, and comments are listened to and fully debated, before agreement is give for the admission. The manager was requested to review the admissions form to ensure it included all of the elements as per the standards. The home does not provide intermediate care. Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s benefit from detailed care plans and are supported by staff that treat them dignity and respect. Their health care needs are met however they are not always sufficiently documented with regard to proactive healthcare. The home’s policy and procedures with regard to the handling and administration of medication need to be reviewed to ensure that the recording of such medication meets with current guidance. EVIDENCE: The service has a belief that it is essential to involve residents in the planning of care that affects their lifestyle and quality of life. Each resident has a plan that has been agreed with them. Evidence was available that resident’s were involved in drawing up personal care plans in the documentation and that they are consulted in reviewing and amending such care plans. Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 11 The inspector viewed and discussed with the manager the care records relating to several residents at Birch Holt. In the care plans viewed there were guidelines in respect to support needed. The home undertakes regular reviews. Formal reviews involving significant professionals and relatives where possible are also undertaken. Risk assessments are in place. However the inspector was of the opinion that they should be more detailed to evidence good practice, choice and independence. The care planning system has improved since the previous inspection. The manager has introduced a more centred planning approach to care plans which will have a socially lead model as its base. This care planning approach has moved away from a healthcare task orientated base to one with includes social and personal goals. It was felt that further improvements could be made with regard to social care planning and fully exploring the residents needs and wishes where possible and opportunities for social development. No requirement has been made at this time. The care plan is used as a working tool and is understood by all staff. It is written in clear language and can be used in an emergency by people who are not familiar with its content. The inspector viewed a sample of care records and specific health care records relating to several residents. Records viewed confirmed resident’s had access to a range of health care inputs as and when required and as part of regular health checks for some of the residents, but this was not the case for all residents care plans viewed. Whilst it was accepted that many of the relatives of resident’s ensure that they have access to Dentists and Opticians etc it was not fully evidenced in the care plans. The home needs to ensure that resident’s have access to their chosen Doctor for medication reviews and health check up’s (if possible), Dentist, Optician in addition to identified specialist health care input. The manager is requested to ensure that the home complies with relevent standards and Regulations. No requirement has been made at this time. It is evident through talking to members of staff at Birch Holt that the emotional health of the resident’s is of a high priority to the home and that staff are pro-active in maintaining and supporting resident’s with their emotional needs in order to maintain their quality of life. The inspector visited the home at 9:10am. During the inspection the inspector noted that resident’s were seen making choices about their lives and were seen to be part of the decision process. A relaxed atmosphere was noted with the resident’s interacting with staff. Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 12 The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of “PRN/As Required” Medication. MAR sheets were seen to be completed correctly and medication was stored appropriately. The manager confirmed that all staff that dispense medication have received appropriate training. PRN or as required medication protocols were not written up. The home could not demonstrate that as required medication is given following an agreed protocol. At the pharmacy inspection carried out on the 9th February 2007 that the MAR sheets should show “to take with food “ or “take before food “. At this inspection some hand written notes were found on the Mar sheets but this was not seen as the best practice by the inspector and should be reviewed. The medication policy was seen to be not very comprehensive and lacked detail in key areas with regard to PRN or as required medication. The home was requested to seek further advice from the CSCI pharmacy Inspector to ensure that advice is sought with regard to MAR sheets, PRN guidelines and prepare a comprehensive medication policy. Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Current residents enjoy a good lifestyle, which meets with their expectations. Relatives are actively encouraged to maintain contact with their relatives and residents are encouraged to maintain choice and control over their lives. The resident’s benefit on the whole from appetising meals and balanced diet offered at the home. However opportunities to improve choice and menu planning are possible. EVIDENCE: The majority of the residents spoken with confirmed they were happy with the lifestyle at Birch Holt and found the level of activities about right. Staff normally arrange activities in the afternoon records are kept of what the activity is. Some of the activities include bingo, ball games, a luncheon club and residents visit a local pub. Residents confirm that Christmas parties and birthdays celebrations are also organised. Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 14 Family and friends feel welcome and know they can visit the home at any time. Staff always make time to talk to visitors and share information with the agreement of the resident. The design of the home provides seating areas within the communal areas of the home where residents can entertain their visitors, in addition to the privacy of their own room. Residents confirmed they are given choices over meals, activities and the pattern of daily life. Evidence was seen that residents can bring in personal items for their rooms and staff confirm this was encouraged. The general feeling amongst residents was that the food was good, however two comment cards completed by residents did say it was always carrots, cauliflower or cabbage. Other comment cards indicated that after tea no further food was available until breakfast. Menus are displayed so residents are aware of the forthcoming meals. The menus seen indicated a well balanced diet. However no clear choices were seen on the menu’s and any alternative such as a salad was in the opinion of the inspector seen as a poorer choice. The home is requested to seek further information from the Royal Institutes of Public Health Guide for Healthy Eating in Care Homes. No requirement has been made at this time. No requirement has been made at this time. Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are aware of their rights with regard to making a complaint and to whom to complain. Residents are protected from the risk of abuse by the home’s Adult Protection policy and procedures. EVIDENCE: Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 16 A copy of the Home’s complaints procedures was seen and evidenced at the previous inspection and it was confirmed by the manager that it includes all the information outlined in the Standards. The inspector enquired if the service had changed or if there had been any amendments. The manager stated that no changes had been made. Residents spoken with felt confident that they are listened to and concerns are taken seriously. It was evidenced at the last inspection that the home is meeting the standard with regard to the protection of residents. No further evidence suggests otherwise during this inspection. The home’s Policy for the Protection of Residents and staff “Whistle blowing” procedure was discussed. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. The majority of staff have been provided in abuse. The manager was requested to ensure that all staff have received training as soon as possible. Evidence was provided that staff have been checked with the Criminal Records bureau. The manager confirmed that all staff have been through the required recruitment checks prior to appointment which includes checking the POVA (Protection of Vulnerable Adults) register. Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Resident’s benefit from living in on the whole a well maintained environment which provides a homely warm atmosphere with safe access to comfortable indoor and outdoor communal areas Residents health is at risk due to the failure of the home to ensure and that the kitchen is maintained in a clean and hygienic state and free from dirt and unpleasant odors. EVIDENCE: Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 18 The inspector observed that the home is set in well-maintained gardens. It was apparent that the individual and collective needs are being met in a comfortable environment. The standard of internal decoration and fixtures and fittings are well maintained and of a good quality. The home benefits from a wide selection of communal area’s thus affording resident’s space should they so wish desire. In contrast to this the kitchen was found to be dirty and unclean. In the view of the inspector ancillary staff are employed in sufficient numbers to ensure that standards relating to food hygiene are fully met. However at time of inspection the kitchen was found to be in a un-hygienic state. Standards of general cleaning, storage of food, procedures / working practices to ensure food hygiene and compliance with Health and Safety legislation was found to be very poor. Many areas of the kitchen were found to be dirty which in the view of the inspector poses a risk of food contamination or a heightened risk to residents of food poisoning. Some out of date food was stored in several cupboards. Opened packets of food were also found along with food crumbs flour, rice loose laying on some of the shelves and in drawers. Food within the fridge was not covered or dated along with uncovered food within the freezer which had freezer burn. The above is not an exhaustive list but provides a picture of evidence that the home has not taken all reasonable steps to ensure the safety of residents and in the view of the inspector was in breach of food hygiene and Health and Safety Legislation. The home is requested to seek advice from the Environmental Health Officer and ensure that its future practice if improved and maintained. The manager was requested to introduce a cleaning audit to ensure that high standards are maintained. The Inspector did recognise that extensive cleaning took place within 24 hrs following the first day of inspection. On the second day of inspection it was found that the kitchen was cleaner and all out of date food had been removed. The manager was made aware that further breaches of regulations could result in formal enforcement action under the Care Standards Act 2000 and Care Home Regulations 2001. Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s’ care, social and emotional needs are promoted by on the whole well trained care staff in sufficient numbers to meet their needs and are protected by the recruitment procedures within the home. EVIDENCE: The ratios of care staff to resident’s is determined according to the assessed needs of residents. Following discussions with staff, resident’s reviewing the rota and observations sufficient staff were on duty. The home employs ancillary staff who work as cleaners, cooks, gardener/ maintenance staff. Thus allowing care staff the time to meet the needs of resident’s. From documentary evidence seen the standard of staff training was adequate overall with the majority of staff completing basic courses. However shortfalls were noted with regard to 50 achieving a NVQ (National Vocational Qualification) Level 2 or above care qualification. The manager confirmed that she would include within the home’s action plan that all staff have completed both adult protection and basic core training. The manager was requested to carry out a training needs analysis and was recommended to complete a up to Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 20 date training matrix which would clearly identify levels of training for each member of staff. Dementia training was also identified as a need within the home to enable staff to support resident’s further as their needs change. No requirement has been made at this time. The manager confirmed that the home now has a development programme for all new staff, which meets Sector Skill’s council’s workforce training targets and ensures staff fulfill the aims of the home and meet the changing needs of resident’s, and that all members of staff receive induction training to specification within 6 weeks of appointment to their posts, and foundation training within 6 months. The home showed that it undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of identity and copies of qualification certificates, seeks two written references, and confirms work status. The home’s recruitment files reviewed were seen to include all the information as required under schedule 2 of the Care Home Regulations 2001 on information given. The home was requested however to review it’s staff files to ensure compliance. Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Resident’s benefit from an overall well run home with an experienced manager in post and is operated in their best interests and their views and opinions are important. However shortfalls were noted with regard to the quality of the Reg 26 provider visits Resident’s can be assured that their personal finances are secure, however the standard of record keeping was poor and the need to have a reconcilable audit trail was needed. Resident’s cannot feel confident that at all times their health and safety is protected EVIDENCE: Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 22 The Manager stated that she has the required qualifications and experience to register with the Commission as Registered Manager and has applied to the Commission to be registered. The service is planned to be user focused, and generally works in partnership with family of residents and with other professionals. The home has a Statement of Purpose that sets out the aims and objectives of the service. The manager has developed systems that monitor practice and compliance with the homes plans, policies and procedures with some shortfalls. The home has developed a health and safety policy that generally meets health and safety requirements and legislation. Throughout the inspection the manager was open and honest and assisted in the inspection. The manager is aware of the issues raised and showed a commitment to work diligently to address them. Quality assurance was discussed and the views and opinions of many of the residents sought. They confirmed a great deal of satisfaction in living within the home and felt confident that their views and opinions were valued by the staff and management. The manager confirmed that the home does undertake quality assurance by means of asking resident’s to complete questionnaires and seeks their views and opinions of relatives. The provider regularly visits the home and completes what is known as a Regulation 26 visit. This requires the owner / provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. However the quality of such Regulation 26 visits viewed were seen to be very poor. In the view of the Inspector, there was very limited detail. The inspector stated to the manager that the visits need to focus on outcomes for resident’s with regard to quality of care, staffing, adult protection, audits of policies and procedures and that they are followed, staff training, activities, health and safety etc. along with speaking to staff and resident’s. Residents and families are encouraged to handle the monies of resident’s who are unable to manage them themselves. The home only deals with the personal monies on behalf of a few resident’s. At present the provider has direct access to their bank accounts. This in the opinion of the inspector does not offer the best solution to protect both the provider and the resident. It was suggested that the provider makes contact with the Residents Monies Officer from the Local Authority for help and guidance. The records for these were viewed and found to be in need of improvement and very poor with regard to providing an auditable clear accounting system. The system in place does not ensure that residents could be confident that the monies were handled securely. Three accounts entries for three residents were audited and did not balance, with small discrepancies. Monies are kept separately in a locked tin in a cabinet. At present a statutory requirement has not been made at this time, Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 23 however the manager is aware of the areas identified for improvement. Failure to improve could result in enforcement action. The inspector viewed records relating to Health and Safety Procedures, maintenance and servicing, and risk assessments. The inspector viewed the Fire Log book, which was up-to-date. The inspector was able to evidence that checks and servicing of fire safety equipment / emergency lighting had been undertaken at the required frequency. Evidence was seen with regard to the servicing of gas boilers, servicing of the lift and electrical tests. Shortfalls were noted with regard to ensuring that standards relating to food hygiene and infection control are fully met. At the time of inspection the kitchen was found to be in a un-hygienic state. Standards of general cleaning, storage of food, procedures / working practices to ensure food hygiene and compliance with Health and Safety legislation was found to be very poor. Standards were however significantly improved on the second day of the inspection following a thorough clean. Further details of this shortfall is also covered by standard 26. Birch Holt Retirement Home DS0000021052.V337430.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 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 1 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 x x 2 Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement To have clear information on medicine administration charts and have PRN (as required) medication administered only following an agreed protocol The medication policy was seen to be not very comprehensive and lacked detail in key areas with regard to PRN or as required medication. It is required therefore that the medication policy is reviewed to ensure that it follows current guidance. The registered person shall having regard to the size of the care home and the number and needs of service users— (j) after consultation with the environmental health authority, make suitable arrangements for maintaining satisfactory standards of hygiene in the care home; Timescale for action 28/11/07 2 OP26 OP38 16(2)(j) 28/11/07 3 OP33 26(1) Whilst it is accepted that regular 28/11/07 reg 26 visits occur the provider needs to ensure that such visits to audit the quality of care within DS0000021052.V337430.R01.S.doc Version 5.2 Page 26 Birch Holt Retirement Home the home include, staffing, adult protection, audits of policies and procedures and ensure that they are followed, staff training, activities, health and safety etc. along with speaking to staff and resident’s. 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 residents 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 Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Birch Holt Retirement Home DS0000021052.V337430.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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