Inspection on 10/05/05 for Birch Lawn Resource Centre

This inspection was carried out on 10th May 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Birch Lawn Resource Centre 26/09/07

Birch Lawn Resource Centre 25/01/07

Birch Lawn Resource Centre 18/10/05

Birch Lawn Resource Centre 18/11/04

Birch Lawn Resource Centre 08/06/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Birch Lawn Resource Centre Sullivan Road Sholing Southampton SO19 0HS Lead Inspector Chris Hemmens Unannounced 10 May 2005 10:00 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 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 Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Birch Lawn Resource Centre Address Sullivan Road, Sholing, Southampton, SO19 0HS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 023 8044 5906 Southampton City Council Pauline Holloway Care Home 33 Category(ies) of PD(E) - 6 registration, with number DE(E) - 6 of places PD - 6 OP - 33 Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of six service users in the category DE(E) may be accomodated at any one time. 2. A total of six service users in the category PD and PD(E) may be accomodated at any one time. 3. Service users admitted in the categories PD and PD(E) may be accomodated in the designated rehabilitation unit. 4. Service users in the category PD may only be accomodated between the ages of 55 yearsand 64 years. Date of last inspection 18/11/04 Brief Description of the Service: Birch Lawn is a purpose-built property providing care and support to 27 6 rehabilitation persons of either sex over the age of 65 years and who are frail or have a physical disability. The home is the responsibility of Southampton City Council and is managed day –to –day Mrs P Holloway is the registered manager for Birch Lawn. The home is situated in Sholing, a residential suburb in the South East of Southampton. It stands on a three-acre site of well laid-out lawns, with shrubs and trees. There is a raised garden, greenhouse and vegetable plot providing opportunities for service users to maintain an interest in gardening. Garden furniture on the patio area enables all service users to enjoy the garden, particularly in the warmer months. The building has two floors with a passenger lift to the first floor. The interior to the building has been pleasantly decorated and appropriately furnished with good quality furnishings. The home has its own shop, hairdressing room, library and bar. A separate Intermediate Care Unit (managed by Birch Lawn) offering residential rehabilitation for six persons who are 65 years of age or over. Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced visit to the home this year. At the time of the inspection the home was holding a staff meeting and the inspector was invited to join. The registered manager Mrs P Holloway assisted the inspector with the inspection, the inspector spoke with three residents and three members of staff. The five requirements made at the previous inspection were reviewed, three requirements had been met and two had not. What the service does well: What has improved since the last inspection? What they could do better: The home could do better improve its systems and procedures to protect residents who wish to handle their own financial affairs to guard against Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 6 financial abuse, and to also safeguard residents and staff against the spread of infection. Southampton City Councils maintenance department carries out the homes maintence or contracts its works out. The manager has little input into who, what, how and when the works are to be carried out and limited access to information on checks carried out by the maintenance department. Southampton City Council could do better to complete identified concerns relating to the safety of the building and empower the manger to have access to records required by the law. It is unacceptable that recommendations made in August 2004 by the Hampshire Fire and Rescue have not been addressed. 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 Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 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 standard(s) The inspector did not inspect the core standards 3 and 6 on this occasion as the home fully met the standards at the previous visit. EVIDENCE: Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 10 The home demonstrates a very good individualised approach to meeting the personal, social and health care needs of the residents in a respectful and dignified way. EVIDENCE: Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 10 Residents each have an individual plan that has been developed using a person centred approach. The plans address all the needs of the residents including their social and emotional needs, and provide specific detail on how the residents are to be supported, providing a consistent approach. The residents with whom the inspector spoke with said the carers were very kind and helped them the way they wished to be helped. The home appoints a carer to a resident who then becomes familiar with the residents support and health care needs. The carer and the resident regularly review their needs, the carer will then notify the manager and other carers of any changes. The manager provided the inspector with evidence that the health care needs of the residents are fully met and reviewed. The home ensures the primary and specialist health care needs of the residents are efficiently responded to and met. At the time of the visit the district nurse and occupational therapist had visited the home. The home is situated close a local health centre and is very well supported by the health care team. The manager demonstrated a very good understanding of her role to ensure the home is fully able to meet the residents health care needs and how she addresses these through reassessment and referral if she believes the home cannot fully and appropriately support the resident. The manager ensures staff receive appropriate training and the home obtains appropriate equipment and support if a resident has a specific health care need. The requirement made at the previous visit to ensure all staff including agency and ancillary staff respect the dignity and privacy of the residents has been met. Staff confirmed that they are aware of the core values of respecting the residents they support, and how new staff ,through the induction process, are supported and supervised by a key member of staff and advised how to address and provide personal support to the residents. The residents with whom the inspector spoke with said they always found the staff to be respectful, allowing them privacy, knocking on their doors before entering and supporting them to maintain their independence. Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14 The home is managed in a way that supports residents to continue to maintain their preferred life style, preferences, and choice and allows them to have control over their lives. EVIDENCE: The residents with whom the inspector spoke with said that they are supported and involved in making choices about their care and daily lives. They said they are offered alternative choices at mealtimes, can eat their meals when and where they like, get and go to bed when they want, choose to take part or not take part in activities provided in the home and receive visitors or go out with their visitors if they wish. Generally the residents said they were very satisfied with the opportunities they have to make choices and the control they have over their lives. One resident spoke at length of the opportunities they had to be involved in activities in the home, such as bingo where she had won enough money to purchase her own TV, arts and crafts and short walks to the local shops. At the time of the visit the local church was visiting the home and a service took place for those wishing to attend. The staff with whom the inspector spoke with demonstrated a very good understanding of the importance to ensure resident’s choices are respected, valued and maintained. One member of staff said “its important that we try as much as we can to support the residents to have a life close to what they had before moving into the home”. However staff felt they do not always have Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 12 enough time to spend with the residents. Staff were observed to be respectful and adopt a relaxed approach. The camaraderie between residents and staff was observed to be healthy. Where safe to do so residents are encouraged to manage their own financial affairs, however for those residents requiring assistance the home/organisation has a facility for supporting them. Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 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 standard(s) 18 The home demonstrates that as far as feasibly possible it protects the residents from abuse, however further work is required to ensure residents are safeguarded against financial abuse. EVIDENCE: Standard 16 was not inspected on this occasion, however the resident with whom the inspector spoke with said they didn’t have any complaints, but knew how to and who to complain to. The residents said they felt very well cared for, and the staff and the manager are very nice, and the home is comfortable. The home demonstrates that staff receive appropriate training and information to provide awareness and ensure correct procedures are followed if they suspect abuse. The staff with whom the inspector spoke with were able to confirm they had received training and were aware of the signs and symptoms, the different types of abuse and whom they would report their concerns to. At the time of the visit the police were undertaking an investigation into a theft of a cheque book and an attempted fraudulent use of this. The home was observed to be cooperating with the investigation and the manager had reported the incident to the appropriate authorities. The procedure for the Protection Of Vulnerable Adults has been put into action and will be followed up with all appropriate authorities meeting to discuss the case and agree specific actions, such as identifying who the perpetrator is, what action will be taken, and establish how the financial systems for the individual and in the home can be improved and safe guarded. Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 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 standard(s) 19, 25 and 26 The home provides a comfortable and clean environment for residents to live, however the timescales of works carried out by the maintenance department needs to improve and the home needs to adopt clearer procedures for managing infection control. EVIDENCE: Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 15 The home provides a homely and welcoming environment for residents to live, it is divided over two floors, providing residential accommodation and a separate rehabilitation unit. The home is able to support four residents at any one time whose needs are considered high, the rooms have been specifically designed to meet their high dependency needs and have been fully equipped with quality furniture and furnishings. The home has adequate communal space that can be shared by all, hairdressing facilities a shop that sells confectionary and toiletries, a bar and a library. The home offers a bright clean and airy environment, which is tastefully decorated and furnished. The home provides a very good laundry and the laundress must be congratulated for the high standard of service she provides. The garden is spacious with a path for easy access around the garden with raised flowerbeds, a patio area and plenty of seating. The residents with whom the inspector spoke with said they liked the home and their bedrooms. All bedrooms seen by the inspector were found to clean, tastefully decorated and furnished with some of the residents’ own belongings and personal items. The home is bright, airy and provides adequate facilities to heat the home, radiators are covered and thermostatically controlled, however the home continues to experience difficulties with the boiler. Some areas of the home feel very warm and others cool. The requirement made at the previous visit to address the problems with the heating system has not been met. The inability to appropriately control the heating places residents at risk of getting too hot or too cold and uncomfortable. The manager is advised to record room temperatures daily throughout the home, monitor and place pressure on the maintenance department to complete the work. At the time of the visit the home was holding a staff meeting, topic of conversation was the laundering of soiled clothing and the potential risk staff were placing themselves at by not carrying out appropriate procedures. The manager the manager informed the inspector that staff were to receive infection control training the following week by an approved trainer and she would ensure the matter is discussed in full and an appropriate procedure is adopted. Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 The home ensures the resident’s needs are met by providing adequate numbers of skilled and competent staff. EVIDENCE: The manager ensures there are adequate numbers of staff on duty to meet the numbers and needs of the residents they are supporting. The manager informed the inspector that she is currently fully staffed, however when there are absences she will call upon agency to cover. When using agency staff the home will try to call upon agency staff who have previously worked in the home and are familiar with philosophy of the home, how the home runs and supports the residents. The inspector spoke with an agency member of staff who said that he felt well supported by the staff and felt the home was very nice and well run. The manager ensures that staff are fully equipped and skilled to undertake their job competently. The home has a rolling schedule of training, which includes mandatory training such as fire, moving and handling and first aid and further specific training relating to the needs of the residents such as abuse and administration of medication. Staff have recently received training from the district nurse to provide specific training in order to support a resident with specific feeding and drinking difficulties. Staff spoke confidently about the procedure they undertake. Staff are encouraged and supported to undertake an NVQ and the staff with whom the inspector spoke with said they felt the home was very good at providing training, and that they were very pleased with the training they had attended. Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 38 The home actively seeks the views and involves the residents in the running of the home. The organisation has adopted a financial system that appropriately manages residents’ monies; however further work is required to ensure those residents who manage their own money are safeguarded against abuse. Standard 37 and 38 was not fully inspected, however the manager must be given full access to records pertaining to the homes maintence and it must ensure it fully complies with the fire regulations as identified in a recent Hampshire Fire and rescue inspection. EVIDENCE: The manager informed the inspector that the organisation has recently redesigned the quality questionnaire for residents and relatives and carry these out on a sixth monthly basis. The manager is advised to forward the outcomes of the questionnaire to the Commission for Social Care Inspection. The manager informed the inspector that she holds regular resident meetings and provides the residents of forthcoming events, any changes and seeks from Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 18 them what they would like to do, their views on how they can improve the home and any changes they would like to see happening. The residents with whom the inspector spoke with confirmed that they attend regular meetings. One resident informed the inspector that they had recently discussed what they would like to do and where to go during the through the summer. Staff also confirmed that arrangements had been made to go on several outings and that the residents regularly discussed what they would like to do and what to have on the menu. The organisation has recently adopted a new system for managing the finances of residents who are unable to do this for themselves or have no one as an appointee. The homes administrators and manager explain the process of how residents can manage their own money, have someone do this on their behalf or how the organisation will do this for them. Residents are provided with lockable storage and are advised on admission how to safeguard their personal property, however following an allegation of theft of a cheque book, further safeguards are required to be put in place. This will be followed up through the Protection of Vulnerable Adults. The manager informed the inspector of a recent fire inspection by a Hampshire Fire and Rescue officer, a report has been received and identifies a number of areas of concern relating to fire doors, emergency lighting, and detecting. The manager informed the inspector that the health and safety manager was in consultation with the fire authority with the report. The manager must notify the Commission for Social Care Inspection of the outcome of the consultation and what works are to take place to rectify the concerns identified. As the registered manager the manger must have access to all records pertaining to the home including those relating to the maintenance of the home. The requirement made at the previous visit for the manager to have access to all records relating the maintence checks on the building such as fire and legionnaires remains unmet, this will be carried over with a tighter timescale for implementation. Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x 1 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x x 3 x 1 x 2 2 Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 20 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 OP25 Regulation 23(2) (c)(p) Requirement The registered manager must send a further action plan to the Commission for Social Care Inspection detailing the nature of the problem with the heating, and timescales for repair. A further failure to complete works to the heating system may result in further action being taken. The registered manager must monitor and record daily the temperature of rooms through out the building. The regiatered manager must introduce a robust system to ensure all residents are protected against financial abuse. The registered manager must introduce a robust and safe procedure for the management and transporting of bodily waste. The registered manager must ensure the requirements made by the Hampshire Fire and Rescue are carried out without delay. The registered manager must have access to all records held in the home.· Timescale for action 30/06/05 2. OP25 23(2) (c)(p) 13(6) 30/06/05 3. OP18 and OP35 30/06/05 4. OP26 16(2)(j) 30/06/05 5. OP38 23(4)(a) (b)(c)(i) (iii) 17(2) 12(1) 13(4) 31/07/05 6. OP26 OP37 OP38 30/06/05 Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 21 23(4) Fire and legionnaire record checks undertaken by maintenance emplyees. This requirement has been repeated a further failure to comply may result infurther action being taken. 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 Good Practice Recommendations Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 22 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Birch Lawn Resource Centre H55-H03 S39103 Birch lawn V218912 100505.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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