This inspection was carried out on 1st December 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 no outstanding requirements from the previous inspection report,
but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Birch Tree Lodge 11 Toller Road Quorn Loughborough Leicestershire LE12 8AH Lead Inspector
Mr Steve Hunnybun Unannounced Inspection 1st December 2005 Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 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 Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 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 Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Birch Tree Lodge Address 11 Toller Road Quorn Loughborough Leicestershire LE12 8AH 01509 415665 01509 415842 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) Aspire Lifestyle Limited Mrs Gillian Gorton Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No additional conditions of registration. Date of last inspection Brief Description of the Service: Linden Lea is a residential home for 4 adults with learning disabilities with three resident at the time of the inspection. Residents all have complex needs including autistic spectrum disorder and epilepsy. The home is situated in a quite residential part of Quorn village and is close to local amenities such as shops and public transport links. The home is well maintained and decorated and has a large garden to the rear. Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second statutory unannounced inspection this year. The inspector examined records, spoke with two residents and two members of staff. Comments from residents were positive. The home was described as ‘very nice’ and ‘lovely’. Both residents said that they like the food; one stated that his favourite is pasta, which was on the menu on the night of the inspection. 14 of the National Minimum Standards were examined. What the service does well: What has improved since the last inspection? What they could do better:
Holes from a hole punch obscure part of the instructions for giving medication. Staff need to have formal adult protection training. The manager must apply for registration as soon as possible. Residents’ files need to be organised in a way that clearly identifies the most recent information. Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 6 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 Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 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 Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Residents’ needs are assessed so that staff are better able to provide individual care. EVIDENCE: All residents had assessments in their files. These were useful documents that Would enable staff to meet residents’ needs. Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Residents assessed needs are reflected in their care plans, they are enabled to make choices and are supported to take reasonable risks. EVIDENCE: All residents have very useful care plans that have been reviewed and are dated. They are very individual and are based on assessed information. Residents had signed aspects of their care plans, indicating that they had contributed to the care planning process. In conversation with the inspector residents indicated that they are given choices in areas such as food and bedtimes. All files contained useful risk assessments that enable staff to safely support them to make choices and to access the local community. Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,16,17 Residents are enabled to be part of the local community. Their rights and responsibilities are recognised. Residents are offered a varied, nutritious diet. EVIDENCE: Files indicated that residents are enabled to access local community facilities such as shops, pubs and parks. Any risks involved are reflected in risk assessments along with strategies to minimise them. Residents are able to access all parts of the property. They can spend time alone in their rooms and are offered a key to their doors. Any restrictions are reflected in risk assessments, which also indicate any domestic tasks residents can do. Staff were observed treating residents with respect and using their preferred form of address. Residents stated that the food is good. The inspector examined the menu book, which indicated a varied, nutritious diet. Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Residents are protected by the home’s medication policy, although mistakes could be made where instructions are obscured by the hole punch. EVIDENCE: Much improvement was noted in the recording of medication. A PRN administration was backed up by incident sheets and the criteria for giving such medication was clearly set out in residents’ care plans. A sheet in the medication folder makes it clear that an ‘o’ on a sheet means ‘not given’. Some sheets did, however, have holes in them from a hole punch that obscured part of the instructions. Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Staff need formal training on abuse to enhance their knowledge and to protect service users. EVIDENCE: Staff who spoke with the inspector stated that they have not received specific adult protection training. They stated that they have read the policy and would know what to do should an accusation of abuse be made. Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Residents live in a comfortable, homely environment. EVIDENCE: All the areas identified in the last inspection report have been actioned. The property has been decorated and looks homely and comfortable. Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 Staff are not trained in adult protection. EVIDENCE: Staff do not have a full programme of training. Staff present stated that they have not had adult protection training. Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 The manager needs to register as soon as possible. Residents’ files need to be reorganised to enable the most recent information to be identified. EVIDENCE: The manager is not currently registered with the Commission for Social Care Inspection. The manager was not present during the inspection and due to staffs workloads it was not possible to discuss quality assurance. On examining residents’ files the inspector noted that in all cases there were a lot of old records mixed in with the current ones. This made it hard to pick out the most up to date information. Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 16 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Birch Tree Lodge Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 1 X X X 2 X X DS0000001758.V270808.R01.S.doc Version 5.0 Page 17 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 YA37 Regulation 8 Requirement It is required that the manager applies for registration with the Commission. Timescale for action 31/12/05 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. 4. 6. 7. Refer to Standard YA20 YA23 YA35 YA41 Good Practice Recommendations It is recommended that an alternative method to a hole punch is used to place medication sheets in the folder. It is recommended that all staff receive training regarding the protection of vulnerable adults. It is recommended that all staff receive a full programme of training. It is recommended that residents’ files be organised to clearly identify the most recent information. Birch Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Tree Lodge DS0000001758.V270808.R01.S.doc Version 5.0 Page 19 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
