Inspection on 03/01/07 for Birch House

This inspection was carried out on 3rd January 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birch House 31/12/08

Birch House 26/09/05

Birch House 06/06/05

Birch House 26/11/04

Birch House 02/08/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

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33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Birch House The Street Appledore Kent TN26 2AF Lead Inspector Michele Etherton Key Unannounced Inspection 3rd January 2007 10:00 Birch House DS0000023198.V301390.R01.S.doc Version 5.2 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 House DS0000023198.V301390.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 Adults 18-65. 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 House DS0000023198.V301390.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birch House Address The Street Appledore Kent TN26 2AF 01233 758527 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 Michael John Rogers Mrs Sylvia Margaret Rogers, Mrs Sharon Ann Colton, Ms Joanne Clare Rogers, Mr Alan Edward Rogers Ms Judy Briggs Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2005 Brief Description of the Service: Birch House is a large, detached property situated in the village of Appledore, on the edge of Romney Marsh. It is owned by the company Nexus Direct and is managed on a day-to-day basis by registered manager, Ms Judy Briggs. Set in its own spacious grounds, access to local facilities such as the village shop and post office, pub and recreation ground are minutes walk away. There is a train station situated a brisk 20 minutes walk from the home and an infrequent public bus service is available. The home has access to a dedicated vehicle and is able to have access to a second company vehicle if required. The home offers accommodation to a maximum of 3 people who have learning disabilities and fall between the age ranges of 18 to 65. The house offers a large communal lounge / diner, kitchen, laundry, WC and spacious lobby on the ground floor. All bedrooms and the office are situated on the first floor, with easy access to an additional WC and large bathroom. Service users with staff support manage the garden and are currently developing a vegetable plot at the back of the garden. A spacious gravelled area allows residents to air-dry clothes without getting muddy. The large front garden is currently being landscaped. Copies of inspection reports can be viewed at the home on request. The basic fee for this service is £2,968.61 per week for a 12 week assessment. A confirmed placement could be contracted at a lower price than the assessment or in some cases at a higher price should assessment prove the necessity of additional input being required. Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key site visit took place on 3rd January 2007 between 09.20 am and 1.40 pm. The manager, Ms Judy Briggs, 2 service users and 2 staff assisted with the process. Two people live at the home at the moment. Both were present and actively involved for the entirety of the site visit. Survey feedback was received from one care manager. Two care plans were ‘tracked’ and these formed the basis of the inspection. All communal areas and private bedrooms (at the invitation of service users) were seen. Both service users were happy to discuss their experience of living at Birch House, and whilst in one case at least it is not viewed as a long term home but as a stepping stone to greater independence, both made it clear that they were satisfied with the home and their support there. The inspection process consisted of information collected before and during the visit to the home. Other information seen included care plans, medication records, staff rota, risk assessments, behaviour guidelines, daily records of individual users What the service does well: The manager and staff consult with service users and actively involve them in the planning and development of the home. Service users can see that their suggestions are put into action, and are encouraged to take control of personal decision making. The assessment and care planning system is good. Service users are informed and consulted about their care plans. The home encourages the development of interests and hobbies and facilitates and enables access to the wider community through an excellent range of interesting activities, educational and work opportunities. The Service users are enabled to develop to their own pace and encouraged to strive for greater independence and the possibility of moving on. Service users are provided with a spacious and comfortable environment that is well maintained, and are encouraged to express their selves within it by displaying their art and achievements. Service users confirmed that their ability to make decisions for themselves has greatly improved following the recent staff changes, they speak openly in front of staff and feel comfortable about commenting on a wide range of areas, they feel listened to and have an awareness of how they would make a complaint. Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 6 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 House DS0000023198.V301390.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Information is provided to all prospective service users but needs reviewing to make it more accessible to them. New service users receive assessment of needs to ensure these can be met by the home. EVIDENCE: The development of a more accessible user guide is still underway, although some progress has been made, timescales for completion have slipped. Revised timescales have been agreed following further consultation with service users. This is an ongoing requirement. No new admissions have taken place since the last inspection. Staff’ confirmed that new referrals are managed by an independent placement officer who undertakes an initial assessment. Once admitted for a trial stay, service users receive a 12-week assessment to ascertain whether their needs can be met within the home and their impact on other service users. Current service users confirmed they are asked for their views of how new people are settling in. Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good; This judgement has been made using available evidence including a visit to this service. Service users have detailed care/support plans, these are clearly written; they reflect how individual needs and wishes are to be supported in health and social care. Service users feel they are encouraged and enabled to take decisions and make choices. Service users are supported to take risks and systems are in place to appropriately assess this, clarity is required around risks associated with service user behaviours. EVIDENCE: . Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 10 Care/support plans of current service users were detailed reflecting individual personal preferences and goals, they have been developed with individuals input, service users confirmed they understood the content of their plans and had signed them. There was evidence of regularly updating and review. Service users indicated that they found the new manager and staff were more supportive and encouraging of them making decisions for themselves, and they were pleased with this as they felt more in control, and less oppressed by restrictions placed upon them. They discussed areas in which they are involved in decision-making and clearly have a greater input into the daily operation of the home. There are systems in place for appropriate risk assessment and risk assessment information was noted for both service users, the service encourages development of outside interests and independence and addresses risk responsibly as part of this. Some risks attached to significant but infrequent behaviour outbursts for one service user were not risk assessed and were not reflected in either care plan or behaviour management guidelines, these are omissions and were fully discussed with the manager during the site visit, and a recommendation made for this to be addressed. Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to develop their interests and hobbies and encouraged to make use of community facilities. Service users are supported to maintain relationships with family and friends. Service users feel their rights are upheld better now, and are encouraged to develop their independence skills. Service users are actively involved in the development of menus and are supported by staff to ensure they eat healthily EVIDENCE: Discussion with both service users indicated that they are supported and enabled to access an excellent range of activities that they show interest in, Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 12 including access to the community through walks, pub visits, meals out, fishing, cinema, etc activities are tailored to the specific interests expressed by the service user, where able to service users are encouraged to undertake work and college placements. In discussion service users confirmed access to their family and friends and how they are supported in this by the staff, staff have been proactive in reinstating contact for one user and in facilitating visits for another. Service users indicated that they have access to telephones and in one case a personal mobile to aid this. Service users indicated that they feel much more in control and free following the changes in staff. They are encouraged to develop independence and to take greater personal responsibility. Service users have keys to their rooms and have free access to all areas of the home except the staff room. Staff ‘ were observed to interact well with users and maintain a friendly, supportive and adult rapport, that seeks user participation and agreement. Service users confirmed their active involvement in the development of weekly menus and the shopping purchased for the house. Lunchtime menus are a free choice and users were observed discussing their preferred choice for lunch with staff, Menu’s are flexible and can be changed to suit service users preferences on the day. Staff’ are conscious of healthy eating and are monitoring weights of service users who are less active and taking action to address problems of weight gain. Records of food intake by individual users are maintained. Mealtimes are informal affairs with staff and service users taking an active part and eating together. Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to undertake their own personal care and are satisfied that care routines are in keeping with their own preferences. Service users are enabled and supported to access routine and more specialised healthcare appointments. Service users are protected by satisfactory arrangements for the management of medication within the home EVIDENCE: In discussion service users indicated that they undertake their own personal care, their daily routines are relaxed and in keeping with their preferences. Staff indicated that prompting only is needed and in one case minimal support in respect of hair care. Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 14 Both users indicated that they are supported with health appointments and have insight into when appointments are due; the home keeps records of health appointments and ensures that service users are supported to attend. Specific changes in health care needs are reflected in care/support plans. The home has addressed a previous requirement to bolt the medicine cabinet to the wall, they have also encouraged the development of greater input by the service users into their own medication regime, currently this is with staff supervision, although there are plans to develop this into full self administration for one user. A second service user stated that they did not wish to take on more responsibility in this area and were happy with the present arrangements and level of input they had. Medication consents are in place. Staff have all received medication training. The home has some very good medication arrangements in place, which include individual PRN guidelines for service users and a daily audit of medications. It could not be evidenced whether the present medication procedure had been revised as required at the last inspection (see standard 40) Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel confident about expressing their views, they feel listened to and that someone will act upon their concerns. Service users are protected from abuse and exploitation by procedures and practice; some minor improvements are needed to supporting documentation EVIDENCE: Service users presented as chatty and very vocal about their views and opinions, discussion with them indicated that they have an awareness that there are people outside of the home that they could go to if they were unhappy with things, they both felt there was a definite improvement in the home since there had been a change in management and staff and they felt more able to express themselves and that staff listened to them. “ If I didn’t think they were listening to me I’d go straight to the top”. The revised service user guide will also contain a more accessible version of the complaints procedure. Pre inspection data received indicated there have been no complaints and this’ was confirmed by the manager, no issues have been reported to CSCI. Service users feel comfortable approaching staff with day-to-day issues and these are sorted out there and then where possible. Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 16 The organisation has provided restraint training for all staff, discussion with the manager as to the criteria for this training was discussed, the manager felt the programme was low level and appropriate for the circumstances at Birch House, concentrating more on diversionary techniques for diffusing situations. The manager should ensure that all training in respect of restraint is undertaken by an organisation accredited with BILD where possible. Behaviour management guidelines are in place, and the home is working to wards ensuring that all parties approve ‘these’. Service users were aware of the content of guidelines and indicated that they experience some restrictions placed on them at times following behaviour outbursts. The manager was reminded of the need to ensure transparency by the home in dealing with behaviours, and recommended to ensure that any restrictions or restraint techniques however low key are clearly recorded in behaviour management guidelines, and discussed at reviews for effectiveness and continued use. The manager advised that staff’ are in receipt of adult protection training Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a spacious, comfortable and clean environment, where they are able to express their personal tastes. EVIDENCE: The accommodation is spacious, light and airy although the style of the house and décor is a little dated, there are signs of some wear and tear but generally the house was in good order, clean, tidy and comfortable. It would benefit from some attention to detail to make it more homely. Bedrooms are large and individualised to reflect personal tastes and interests, service users were satisfied with their content, but expressed interest in moving rooms to better suit their own needs, this was being discussed with them by staff as to how to progress this. Shared space is large and comfortably furnished. Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 18 There is a good-sized garden and service users are encouraged to take an active part in maintaining it. Service users confirmed using it for recreational use such as football and barbecues etc. There is a dedicated office/sleep in room for staff. There are sufficient toilet/washing facilities and service users also have sinks in their rooms. Service users have use of a laundry room, which is separate to the kitchen, and reduces risk of cross infection. The home is maintained to a good standard of cleanliness and Service users confirmed that with staff they are actively involved in cleaning routines to support this. Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate, This judgement has been made using available evidence including a visit to this service. Service users feel well supported by a satisfactory number of staff, evidence from staff suggests that staff recruitment and training are being undertaken appropriately, but this needs to be more clearly evidenced in documentation and records kept within the home. EVIDENCE: The staff team for Birch and its sister Home Robinson’s Farm have now been amalgamated. Staffing at Birch House has been reviewed and a decision to increase staff on day shifts to two has been implemented. As a consequence, service users occasionally have unfamiliar staff working with them; care is taken to ensure that an experienced and familiar staff member is also on the roster. A service user reported that “I don’t like it when someone comes that doesn’t know me and what help I need” but agreed that newer staff were usually accompanied by experienced staff. The home has an NVQ qualification training programme, and 60 of staff across both Birch and its sister home are now trained. Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 20 Staff files are not currently kept at the home and could not be viewed at this visit. Discussion with staff and the manager indicated that recruitment procedures are happening and are in keeping with the expected standard and that appropriate vetting is being undertaken, it is necessary for the home to be able to evidence this clearly and it is recommended on this occasion that they progress their decision to make staff records available in this home. The home were unable to evidence whether the recruitment policy had been updated as required following the last inspection, this remains outstanding (see standard 40) Discussion with a newer staff member indicated that following interview they had received a period or orientation and had undertaken induction that involved the completion of a workbook in line with ‘skills for care’; they also confirmed completion of core skills training. The manager reported that staff have individual training profiles these were not available to view. Pre-inspection information indicated that staff’ have had access to a range of training and this was confirmed in discussion with them during the site visit. Evidence provided by the manager and staff indicates that a training programme is in place and staff are receiving appropriate induction, core skills and specialist training, there is currently an absence of documentation to support this, and it is a recommendation on this occasion that the home develops training records within the home. The new manager has identified that there are a number of shortfalls within current documentation and will continue to address this. A requirement has been issued in respect of this (see standard 41). Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41,42 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home is well managed. Quality assurance systems need strengthening. Records in respect of policy and procedures are in need of updating and development, systems are in place to promote and protect the health and safety of service users and staff but shortfalls in supporting documentation need to be addressed. EVIDENCE: The new manager is undertaking an NVQ4 and RMA and has experience of managing other services. She has identified a number of areas for Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 22 improvement and has begun to implement some changes already. Service users indicated they feel happier with the new manager and staff team. The manager has indicated a desire to promote independence where this was the choice of the service users and to provide a more user focused service, she is proactive in consulting with them, and is open to ideas and suggestions from users and staff. Staff seemed satisfied with current management arrangements and confirmed they were receiving supervision, training and staff meetings and that their views were being taken account. Consultation with service users informally is good with verbal evidence of this influencing service development. The home uses service user questionnaires but was unable to provide evidence of analysis of feedback or the publication of a report of outcomes. There are some very good quality assurance measures in place but these are stand alone and do not form part of a formal programme of self assessment and quality assurance. Service users confirmed they do feel listened to and that the manager or the service is responsive. The manager reported that there is daily feedback in respect of service quality and delivery, but this cannot be evidenced. These areas were fully discussed with the manager. The home are required to strengthen their quality assurance system in the areas highlighted The home are still to address an outstanding requirement in respect of evidencing updates of medication and recruitment policies, consideration should be given to ensuring that updated policies are dated, record clearly who has updated them and give a review date. The manager has identified shortfalls in records kept within the home which previously would have been brought to the home for announced inspections there is clearly a need for the home to develop this separately and they are required to ensure that records required by legislation for the protection of service users are in place, updated and in good order. The manager has indicated in pre-inspection information that all appropriate checks and servicing have been carried out, whilst there was evidence that previously this had been undertaken routinely proof of more recent updates have not been retained in the home, as a consequence the manager has been asked to submit copies of some servicing to CSCI post site visit, this indicates that updates are now due and the manager has advised that this has been requested and is in hand. It is recommended that information relating to the servicing of equipment, and services etc be retained within this unit. Staff have access to health and safety training. There is a minimal incidence of very minor accidents and these are recorded, Use of formal incident reporting systems needs strengthening. Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 23 The manager advised that the home is too small to warrant more formal fire alarm systems and has smoke detectors only in place, it is recommended that the manager reviews the present fire safety arrangements in line with the New Fire services safety order 2005. There is an ongoing maintenance programme and the home has access to a maintenance team who will undertake priority works more urgently if needed. Birch House DS0000023198.V301390.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 Adults 18-65 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 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 2 X 2 X Birch House DS0000023198.V301390.R01.S.doc Version 5.2 Page 25 Yes 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 YA1 Regulation 5 Requirement Simplify service user guide to enable greater accessibility to residents. (Not met within timescale of 1/7/06) To develop quality assurance systems to evidence self audit systems and how staff and user feedback influence service development Review medication & recruitment policy and procedure to reflect current legislation and good practice (previous requirement timescale 01/08/05, and 1/1/06 extended) Timescale for action 31/03/07 2 YA39 24 31/03/07 3. YA40 13 (2), 18, 19. 01/02/07 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 YA9 Good Practice Recommendations Assessment of risks to staff and other users from DS0000023198.V301390.R01.S.doc Version 5.2 Page 26 Birch House 2 YA23 3 4 5 YA34 YA35 YA42 significant but infrequent behaviour outbursts from a service user, these should be accurately reflected in care plan and behaviour guidelines All parties should agree behaviour management guidelines’ where possible. Restrictions or restraints should be clearly recorded in behaviour management guidelines and reviews and their use and effectiveness discussed and reviewed. Staff files are to be available for inspection within the home to provide evidence that staff recruitment is sufficiently robust. Evidence of staff training matrix and individual training profiles to be available within the home Home to review fire safety arrangements in line with Fire safety Order 2005. Information relating to the servicing of equipment, and services etc is retained within the home. Birch House DS0000023198.V301390.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 House DS0000023198.V301390.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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