Inspection on 26/09/07 for Birch Lawn Resource Centre

This inspection was carried out on 26th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Lawn Resource Centre 25/01/07

Birch Lawn Resource Centre 18/10/05

Birch Lawn Resource Centre 10/05/05

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 Hampshire SO19 0HS Lead Inspector Janet Ktomi Unannounced Inspection 26th September 2007 09:00 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 Lawn Resource Centre DS0000039103.V344316.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 Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birch Lawn Resource Centre Address Sullivan Road Sholing Southampton Hampshire SO19 0HS 023 8044 5906 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) Southampton City Council Pauline Holloway Care Home 33 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (33), of places Physical disability (6), Physical disability over 65 years of age (6) Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of six service users in the category DE(E) may be accommodated at any one time. A total of six service users in the categories PD and PD(E) may be accommodated at any one time. Service users in the category PD may only be accommodated between the ages of 55 years and 64 years. 25th January 2007 Date of last inspection Brief Description of the Service: Birch Lawn is a purpose-built property providing accommodation, care and support to up to thirty-three people of either sex over the age of 65 years and who are frail or have a physical disability. The home is situated in Sholing, a residential suburb in the South East of Southampton. All bedrooms are single with some offering en-suite facilities. Appropriate bathing, WC and communal facilities are provided. Birch Lawn 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 people to maintain an interest in gardening. Garden furniture on the patio area enables people to enjoy the garden, particularly in the warmer months. The building has two floors with a passenger lift to the first floor. The home has its own shop, hairdressing room, library and bar. The home is owned by Southampton City Council and is managed day-to-day Mrs P Holloway who is the registered manager. Fees are £371 per week. Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains information gained prior to and during an unannounced visit to the home undertaken on the 26th September 2007. All core standards and a number of additional standards were assessed. The inspector would like to thank the people who live at the home, the manager and staff for their full assistance and co-operation with the unannounced visit. The visit to the home was undertaken by one inspector and lasted approximately seven hours commencing at 09.00 am and being completed at 4 p.m. The inspector was able to spend time with the registered manager and staff on duty and was provided with free access to all areas of the home, documentation requested, visitors and people who live at the home. Prior to the visit the manager completed an annual quality assurance questionnaire, information from which is included in this report. Comment cards were returned from one District Nurse and one care manager. The inspector met with a visiting health professional during her visit to the home. Comment cards were sent to the home for distribution to people who live at the home and their relatives/visitors. Twenty-three comment cards were received from people who live at the home and fourteen relative responses were received. Seven staff members also completed comment cards. Information was also gained from the link inspector and the home’s file containing notifications of incidents in the home. During the visit to the home the inspector was able to meet with and talk to many of the people who live at the home and two visitors. What the service does well: The home has a comprehensive pre-admission procedure, which includes a day’s assessment visit. This ensures that people are able to make an informed decision as to whether to live at the home and that the home can meet their needs. All evidence, including comments from external health and social care professionals, indicates that the home ensures that people’s health and care needs are fully met. Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 6 The home provides a range of activities including outings and supports people’s leisure interests. People living at the home stated the food is always/usually good with choice available. The home actively encourages comments, including complaints, from the people who live there and takes appropriate action to rectify any issues raised. The home employs appropriate numbers of care and ancillary staff that ensure that peoples needs are met. Staff receive the necessary training and good recruitment procedures are in place. What has improved since the last inspection? What they could do better: There were no requirements or recommendations made following this inspection. Please contact the provider for advice of actions taken in response to this Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 7 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 Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 8 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 Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 9 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): 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All people are assessed prior to moving into the home to determine that their individual needs can be fully met. People, or their representatives, are able to visit the home prior to admission to assess the quality, facilities and suitability of the home. Terms and conditions of residency are provided to all people who live at he home. Standard 6 is not applicable, as the home does not provide intermediate care. EVIDENCE: The registered manager explained the homes admission procedure and three pre-admission assessments were viewed, two for long term admissions and one for a short stay (respite) admission. Everybody is admitted to the home via the local social services care managers. Following an initial telephone assessment the home obtains a copy of the care management assessment. If these indicate that the home would be able to meet the persons needs the Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 10 person is invited to visit the home for a day assessment where more detailed information (including a comprehensive moving and handling assessment) may be gained and the prospective person can make an informed decision as to whether they would like to live at the home. On the day of the inspectors visit one person was visiting the home for a days assessment. The home has an assessment tool that covers all the relevant areas necessary for the home to decide if it is able to meet a prospective persons needs. The manager was clear about the level of care needs the home can accommodate. The home has a high occupancy rate and the manager stated that there is no pressure to admit people whose needs they cannot meet. The inspector was able to speak with the relative of a person recently admitted who confirmed the above procedure had occurred and that she had had enough information about the home. The home does accept emergency admissions in which case information from the care manager is obtained and the assessment completed once they have been admitted. Staff spoken with confirmed that they were aware of and involved in the care needs assessments. A member of care staff is allocated to undertake the care needs assessment for people visiting the home for a pre-admission day. Staff stated they felt they had the necessary skills to undertake the day assessment and were clear about how and why this is undertaken. Twenty-three comment cards were received from people who live at the home. The majority stated that they had received a contract and that they had received enough information about the home before they moved in, the remainder stated that they could not remember. Copies of terms and conditions were seen in care plans and had been signed by the person or a relative. Statements including ‘my daughter came in and dealt with it – but I’m very satisfied’, ‘I have been here before for respite so I knew what it was like’ and ‘lived near so knew about it’. Another stated ‘I was allowed to stay for several weeks which allowed me to make a decision on whether to stay or not.’ Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 11 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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are set out in an individual plan of care. Medication is appropriately stored and records fully maintained. People are treated with respect. EVIDENCE: Three care plans were viewed; two for long stay and one for a respite stay person. Care plans contained all the necessary information for staff to ensure that all aspects of health, personal and social care needs could be individually met. People have a detailed plan of care and a daily living plan and separate night plan. Plans are reviewed on a monthly basis and people are able to sign their care plans and reviews if they wish. More formal reviews involving social services are undertaken after people have lived at the home for four weeks and thereafter yearly unless care needs change significantly. Seven care staff completed surveys and all stated that they always or usually have up to date information about the care needs of the people they are Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 12 looking after. Comments being added ‘care plans are updated for clients regularly and during each staff handover we read through clients individual contact sheets’. Comment cards from the people who live at the home stated that they always or usually received the care and support (including medical care) they need. Relatives comment cards also confirmed that they felt that the needs of people living at the home were met. A comment card from a local district nurse stated that the home seeks advice and acts upon it to appropriately manage people’s health care needs. Also stating ‘the district nurses are very impressed by care at Birch Lawn, people are treated as individuals and with care and respect.’ Another health professional visiting the home confirmed these views and they were echoed in the comment card from a care manager who added ‘suitable health care arrangements were made after problems were noticed and raised by staff’. Discussions with people during the inspectors visit indicated that they felt their health and care needs were fully met and that staff always treated them with dignity and respect. Observations of staff interactions and all comment cards received confirmed that people are treated with respect and their right to dignity maintained. Comment cards received from people confirmed that staff listen and act on what they say. The home provides only single bedrooms ensuring privacy during personal care tasks. Following the previous inspection a recommendation was made that the homes medications trolley stored in an upstairs treatment room be secured to the wall and that the controlled medications cupboard be secured in line with the relevant legislation. These had been done. A requirement was made that the Medications Administration record sheets must be fully completed. The manager stated that she has implemented a weekly check on the Medication administration records. The inspector was shown how the home manages medication. The arrangements for ordering, storing and administering are appropriate. The duty care coordinator who has undertaken external training administers medication. The medication administration records were viewed and found to contain one gap. The home supports people who wish to selfadminister their medication and assessments were seen in care plans for people who wish to do so. Each bedroom has a secure storage facility. Birch Lawn Resource Centre DS0000039103.V344316.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. Family and friends are able to visit. People receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. People and relatives confirmed to the inspector that they are able to choose where in the home they spend their day, many were seen to spend time in the homes lounge with others remaining in their bedrooms. A popular place to sit being the large area inside the entrance hall that affords views of the gardens and easy access to all parts of the home. Life story information is included in care plans with daily living and night care plans stating specific requests such as times people like to get up and if they Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 14 like a morning drink in bed. People confirmed to the inspector that they are given choice over their meals with options being chosen on a daily basis. Bedrooms seen contained personal items brought into the home. Care plans and assessments include information about leisure activities, catering and religious needs. People stated that they are able to get up and go to bed at times of their choosing. Care plans included information about peoples favourite television programmes those seen stating what sport people had enjoyed watching and playing. The manager explained that there was a church service in the home on a regular basis, and that this was usually well attended. An activities list was noted on display in the dining room. This listed activities planned and provided by care staff and external groups. The home also organises minibus trips out to places selected by the people who live at the home. The Friday following the inspectors visit a boat outing had been organised. Twenty-three people completed comment cards and stated that the home provides activities. The home has a craft room where people were undertaking craft activities on the afternoon of the inspectors visit. The home has very pleasant and extensive gardens surrounding the home. Two of the people who live at the home are very actively involved in the garden and discussed this with the inspector. They are supported with trips to garden centres to purchase bulbs and bedding plans that are funded via the homes amenity fund. The manager identified in the homes annual quality assurance assessment that key staff are to attend age concern activity training courses. The inspector was able to meet two visitors with comment cards from other relatives stating that they are able to visit at any time and kept informed about issues affecting their relative. The home has a good-sized dining room, with pleasant views to the garden, where many people choose to have their meals. People stated that the food is always/usually good and choice provided. The inspector was present for the main lunchtime meal. The food appeared well presented and appetising. Drinks and snacks are also available throughout the day with people confirming this as well as the inspector observing people being given morning and afternoon hot drinks and biscuits. The need for special diets or supplements is recorded pre-admission and a person was observed being given a supplement drink. The home has a large, well-equipped kitchen. Discussions with the cook indicated that she is aware of special diets and the inspector observed the menu sheets which confirmed that choice is available at all meals. The cook stated that the food budget has been increased in recent months. The home has been inspected by the environmental health department and no significant issues were identified in respect of food hygiene. Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 15 Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. People are protected from abuse. EVIDENCE: The home makes use of the corporate complaints policy and procedure, details of which are included in information provided to people using the service. Comment cards returned from people who live at the home and their relatives indicated that they were aware of how to complain. Comment cards and discussions with staff confirmed they were aware of what to do if a person complained or raised an issue. The manager identified in the homes annual quality assurance assessment that the home had receive twelve complaints in the past year. The inspector viewed the records in respect of these, which had all been resolved ‘in house’. Discussions with people during the inspectors visit and the record of comments indicated that people feel able to make their views and opinions known and are not afraid to raise issues with the homes staff or management. The home has a policy and procedure relating to safeguarding adults and ensuring that people are not at risk of abuse. Care staff have had safeguarding Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 17 adults training as seen in the managers training matrix, certificates in files and confirmed by staff. Discussions with care staff indicated they had a good understanding of adult protection and what they should do if they suspected abuse may have occurred. This included ancillary staff such as housekeepers. The report following the previous inspection in January 2007 stated that the home had made appropriate use of safeguarding policies in the past. The homes policies and procedures in respect of recruitment and people’s personal finances should ensure that unsuitable people are not employed at the home and that people will not be financially abused. Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, safe, generally well-maintained home that meets their individual and collective needs. EVIDENCE: The manager showed the inspector round the home towards the start of the inspection visit. Following this the inspector was able to move around the home unaccompanied. The tour of the building showed the home to be clean and tidy throughout and there were no undue odours. At the time of the visit the home was comfortably warm throughout. People confirmed that the home was warm and clean. The home is generally well maintained with contractors provided via the council. Some areas of the home are showing signs of wear. The manager Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 19 stated that new carpets are due to be laid in the upstairs corridors which are also due to be repainted. The ceiling in one WC was seen to be stained due to leakage from the flat roof above. The manager stated that the roof had now been repaired and had not leaked during the heavy rain earlier in the week and that the ceiling would be repainted. No requirements are made in connection to the carpets or decoration, as there are plans already in place to address these areas. The home has a range of communal areas including, good-sized dining room, lounge with bar/shop, library, hairdressing room, small upstairs lounge, foyer and pleasant patio and gardens. A small kitchen is also available for use by people who live at the home or their relatives. All parts of the home are accessible via a passenger lift. Communal areas were adequately furnished although some chairs did appear to be showing signs of wear. Adequate bathing and toilet facilities are available with any necessary aids in place. The inspector viewed a number of bedrooms. These vary in size, with a small number having en-suite facilities, the others being equipped with a washbasin. People stated they were happy with their bedrooms and these were seen to contain personal items including home entertainment and mini fridges. People confirmed that they could lock their bedroom doors and had a lockable facility within their rooms or valuables. The homes laundry was visited and is appropriate and fit for purpose with industrial machines capable of washing to disinfection standards. Members of staff spoken with confirmed they had received infection control training and had access to all the necessary equipment to prevent any risk of cross infection such as disposable gloves and aprons. Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 20 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs appropriate numbers of care and ancillary staff that ensure that peoples needs are met. Staff receive the necessary training and good recruitment procedures are in place. EVIDENCE: All comment cards, from people who live at the home, relatives and professionals were positive about care staff. One relative commented ‘they usually provide excellent care, very attentive and understanding’, also ‘my mother only has praise for all the staff’. People who live at the home stated in comment cards ‘I am pleased with the staff who help me. My key worker is very good’. Professional comment cards were also positive about staff. One issue raised on comment cards was that of agency staff. This was discussed with the manager who stated that the home has managed to fill some vacant posts and the requirement for agency staff will be greatly reduced in the future. On the day of the inspectors visit a newly recruited member of staff visited the home to organise her induction shifts with the manager. The home also takes part in the Chinese Nurses Project and two qualified Chinese nurses will be working at the home for the next six months. The manager Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 21 stated that when shifts need to be covered these are first offered to the homes staff before the agency is contacted. Duty rotas were seen during the visit to the home. Duty rotas stated that four care staff, a care coordinator and a cook, kitchen assistant and two cleaners, are provided in the morning; four care and a care coordinator and a cook in the afternoon/evening and two awake care (one a care coordinator) at night. People and visitors stated that there are sufficient staff on duty. During the inspectors visit staff on duty corresponded to those on the duty rota. Care staff stated that they generally have sufficient time to meet people’s needs and throughout the inspection care staff appeared to have time to meet people’s needs. The manager stated that she does have some flexibility to increase staffing levels should a particular need arise. The manager provided training and qualification information during the inspection and on the annual quality assurance assessment. The home has a high number of care staff with or studying for an NVQ in Care of at least level 2. With nine of the sixteen staff having the qualification and six further staff undertaking this course. The manager has now organised a training matrix so that she can readily identify who requires training or updates. The training matrix indicated that staff have received the necessary training to meet peoples individual and collective needs. The matrix also indicates when training and updates are scheduled and who should attend. In addition all staff have personal file in which the inspector viewed training certificates. In addition to mandatory training staff have also received in house training relevant to the specific needs of people living at the home such as dementia, Parkinson’s, PEG feeding etc. Care staff stated on comment cards and to the inspector that they felt they had the necessary training to meet people’s needs. The recruitment records for the three newest staff were viewed. These contained all the required information and confirmed that all staff are fully checked including references, CRB and POVA checks prior to commencing employment at the home. The homes recruitment procedures should ensure that unsuitable people are not employed at the home. The manager explained the homes induction procedure that includes the Skills for Care induction and the allocation of a mentor within the home. Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 22 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, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the necessary skills and experience to ensure that the home is appropriately managed and run in the best interests of the people who live there. People’s financial interests are safeguarded. Staff are appropriately supervised and annual appraisals have been completed. The health, safety and welfare of people and staff are promoted. EVIDENCE: The manager has been the registered manager of the home for approximately seven years and has the necessary qualifications in management and care. Throughout the inspection visit the manager demonstrate knowledge of the Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 23 people who live at the home and the mechanisms by which support can be obtained when necessary. Within the annual quality assurance assessment the manager demonstrated that she is clear about the responsibilities she holds including budgets for the home. Within comment cards and during discussions, people who live at the home, visitors and staff stated that they felt they could approach the manager and that the home was effectively managed. The manager undertakes satisfaction questionnaires for people who stay at the home for short/respite stays. The home also undertakes monthly residents meetings the minutes of which the inspector read. These indicated that people are kept informed about any forthcoming issues/changes such as the new Chinese nurses and feel able to raise issues. Minutes also indicated that the manager has addressed issues raised in previous meetings. Minutes of each months meeting are provided to people who live at the home with a copy of the monthly newsletter. The inspector also saw regulation 26 reports completed by a person nominated by the provider. These were detailed and identified issues and followed up on these. The home also holds staff meetings the agenda for the next meeting was seen in the staff room for people to add items too. The home does not does not act as appointee or hold valuables for people living at the home. The council does provide individual banking account facilities should people require this from which the manager can assist people to assess personal money as they request. These accounts and the systems are fully audited by the council. As previously stated every room has a lockable facility in which people can keep any valuables. Staff confirmed that they felt appropriately supervised. All staff receive an annual appraisal and have formal recorded supervision every two months. This is managed on a cascade system with the manager supervising the care coordinators and they in turn supervising an identified number of care staff. Care staff confirmed in comment cards and during discussion that they are appropriately supported and supervised with an on call system in place when the manager is not at the home. Various records were viewed during the inspectors visit. All records were appropriately stored with access only available to people who should have access. Records were seen to be well maintained. During the inspectors visit there were no concerns in respect of health and safety identified. The home has complied with the requirement made following the previous inspection that they must ensure the recommendations made by the Hampshire Fire and Rescue service. The home is generally well maintained and clean, with staff having relevant training to meet people’s needs. Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 24 Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 25 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 X 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 3 X 3 X 3 3 3 3 Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Birch Lawn Resource Centre DS0000039103.V344316.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Lawn Resource Centre DS0000039103.V344316.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. 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