Inspection on 10/11/08 for Birchdale

This inspection was carried out on 10th November 2008.

CSCI found this care home to be providing an Adequate service.

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

Birchdale 22/05/08

Birchdale 28/11/07

Birchdale 04/07/07

Birchdale 21/07/06

Birchdale 18/10/05

Birchdale 03/06/05

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOMES FOR OLDER PEOPLE Birchdale 6 Tennyson Avenue Bridlington East Yorkshire YO15 2ES Lead Inspector Diane Wilkinson Unannounced Inspection 10th November 2008 10:30 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 Birchdale DS0000062588.V373104.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. Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchdale Address 6 Tennyson Avenue Bridlington East Yorkshire YO15 2ES 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) 01262 676275 01262 674908 birchdale@pcslimited.net Pennine Care Services Ltd. Position vacant Care Home 25 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (25) of places Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places 25 2. Dementia - Code DE, maximum number of places 25 The maximum number of service users who can be accommodated is: 25 22nd May 2008 Date of last inspection Brief Description of the Service: Birchdale is a privately owned care home that is registered to provide care and accommodation for a maximum of 25 older people, including those with dementia related conditions. It is a period property that is located in the centre of Bridlington, in the East Riding of Yorkshire. The home is in close proximity to local amenities including transport, shops, health care and leisure facilities. Private accommodation is provided over three floors in nineteen single rooms and three shared rooms. Some bedrooms have en-suite facilities, and some of these include a shower. The first and second floors of the home are accessed via a passenger lift. Communal accommodation is provided in two lounges, a dining room and a conservatory. There is a small courtyard style garden at the rear of the property. Information about the home is provided in a statement of purpose, a service user’s guide and a brochure; these inform service users and others about the scope and nature of the care and facilities on offer. The manager told us that fees charged are between £300.00 and £346.00 per week. Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on the 22nd May 2008, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 10.30 am and ended at 5.00 pm. On the day of the site visit the inspector spoke on a one to one basis with a resident, a visitor, two members of staff and the manager. Inspection of the premises and close examination of a range of documentation, including two care plans, were also undertaken. The manager submitted information about the service prior to the site visit by completing and returning an Annual Quality Assurance Assessment (AQAA) form. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. As part of the inspection process we contacted a selection of social care professionals to ask them some questions about the service provided by the home. The people we consulted told us that there had been improvements to the environment and to the meals provided by the home, and that residents were well looked after by staff. At the end of this site visit, feedback was given to the manager on our findings, including requirements and recommendations that would be made in the key inspection report. What the service does well: Daily records are a thorough account of how a person has spent their day, including food and fluid intake, any visitors seen and any activities undertaken. Staff consult with other professionals to ensure that the health care needs of residents are met. Residents are supported and encouraged to follow their chosen lifestyle and to continue with hobbies and interests. Food provision at the home is good and there is a choice of meal at every mealtime. Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 6 50 of care staff have achieved NVQ Level 2 in Care or above. Monies held on behalf of residents are managed safely and money is held securely. The home is well managed and staff are working well as a team to provide good care for residents. What has improved since the last inspection? What they could do better: A medications fridge should be purchased to ensure that medication such as insulin and antibiotics is stored safely and at the correct temperature. Any incidents where there are indications that abuse may have taken place must be referred to the local authority under safeguarding protocols. The CSCI should be informed of any accidents or incidents to residents that require medical intervention via a Regulation 37 notification. All equipment and appliances should be serviced on a regular basis to ensure that residents and others are protected from harm. This includes fire safety equipment. Fire drills should be held to ensure that residents and staff know how to react in an emergency situation. Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 7 The quality assurance system should be fully operational to ensure that residents and others are able to affect the way in which the home is operated. 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. Birchdale DS0000062588.V373104.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 Birchdale DS0000062588.V373104.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): 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents will be assessed prior to their admission to the home and only admitted if it is considered that their assessed needs can be met. EVIDENCE: There have been no admissions to the home since the last key inspection. This is partly because the local authority suspended placements to the home as a result of concerns about management arrangements and the misunderstandings around safeguarding protocols and reporting. Following support for the manager from staff working for the local authority, this suspension has now been lifted. Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 10 The registered provider plans to offer respite breaks to people in need of a holiday but who require the services provided by a care home rather than a hotel. A brochure has been produced advertising this service as ‘Seabreaks’. The manager told us that a new assessment form has been devised and that this will have to be completed by applicants for this service; this was seen on the day of the site visit and was considered to be a full needs assessment. The manager told us that the same assessment form would be used for anyone who enquired about respite care at the home, and that a similar form is available for anyone enquiring about permanent care. We noted in the other care plans examined on the day of the site visit that all residents have some form of care needs assessment, and that the information gathered via these assessments is used in the development of an individual care plan. Birchdale DS0000062588.V373104.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Health care needs are met in a way that respects a person’s privacy and dignity; this is recorded in and supported by well-maintained care planning documentation. Some minor improvements in the storage of medication would improve safety arrangements. EVIDENCE: We examined the care plans for two of the residents living at the home. All included a care needs assessment and a care plan, and care plans had been signed by the resident concerned whenever this was possible. Daily reports were thorough and included information about how people had spent their day, their food and fluid intake and other relevant areas of their individual care plan. Key workers record a weekly and a monthly report that summarises a person’s care provision for that period of time, although some of these were out of date. We noted that care plans included a photograph of the resident concerned; a photograph is useful in assisting new staff with identification and Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 12 in assisting the emergency services should someone go missing from the home. Care plans include information about all contacts with GP’s, district nurses and other health care professionals. This includes the reason for and the outcome of the contact. A person’s dietary requirements are recorded and people are weighed monthly as part of nutritional screening. We saw evidence that health and social care professionals are consulted appropriately on behalf of residents. For example, one resident told staff that they wished to go on a weight reducing diet. Staff contacted the GP for advice, as the resident concerned has diabetes. A social care professional told us that residents are well looked after by the staff at the home. Care plans include a body area map so that any injuries or sore areas can be recorded; these documents were being used appropriately. None of the current residents require pressure care equipment but the manager told us that they liaise with the district nurses when anyone requires this service. They have recently obtained a pressure care mattress for someone who was very ill, and the district nurses visited twice daily to assist with tissue viability and pressure care for this person. There should be a risk assessment in place for any bed rails that are used by residents, and there should be evidence that bed rails are checked for safety on a regular basis. We observed on the day of the site visit that staff respect each individual’s privacy and dignity. One person had a visitor and they were shown into the dining room so that they could talk to each other in private. Residents are currently accommodated in single rooms, so they are able to meet visitors and health care professionals in their bedroom for privacy if they wish to do so. The manager told us that one person expressed concern about other people going into their room; a lock was provided on the bedroom door and the resident was given a key. There is another bedroom with a lockable door should a resident request this. We examined the medication administration records and storage arrangements for medication on the day of the site visit. The medication administration records (MAR) included a photograph of each resident to ensure correct identification, and we noted that there were no gaps in day-to-day recording. In addition to the MAR sheet, we saw that there is a separate sheet in use that records any additional notes, for example, a resident’s use of inhalers and the reason why medication was not administered on a particular occasion. We saw evidence that all of the staff that are responsible for the administration of medication have now completed appropriate training, and there are sample signatures available for this group of staff so that medication records can be checked for accuracy and authenticity. The storage arrangements for controlled drugs are appropriate and secure and we examined the records made against the actual medication held; both were Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 13 found to be accurate. A medications fridge has not yet been purchased for the storage of medication that requires keeping at a low temperature, but the manager told us that she is in the process of purchasing one. The home’s medication policy has recently been updated; the inspector intends to check this at a later date and inform the organisation if any further amendments need to be made. Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 14 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to maintain their chosen lifestyle and to continue with their hobbies and interests, and visitors to the home are always made welcome. Residents and visitors tell us that meal provision at the home is good. EVIDENCE: Care plans record information about a person’s family relationships, life history, hobbies and interests and likes and dislikes. We observed that residents are supported to live their chosen lifestyle – one person goes out into the town every day. A person’s religious beliefs are recorded and residents are supported to attend a church of their choice. A record is kept of how people spend their day; this records such things as family visits, time spent out of the home with relatives, listening to music, laughing and joking with staff and time spent with their key worker. Key workers record a summary of a person’s care provision on a weekly and a monthly basis, although some of these records were out of date. Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 15 There is no activities coordinator employed at the home, but the manager told us that, due to the current low occupancy levels, staff have time during the day to spend with residents, including spending one to one time with people. We observed this on the day of the site visit. The manager and staff acknowledged that they could be taking advantage of the current low occupancy levels by arranging more outings for some of the residents who enjoy a trip out. We spoke to a visitor on the day of the site visit. They confirmed that staff always make them feel welcome, that they are always offered refreshments, that they are invited to stay for meals and that they are kept in touch with events regarding their relative. They told us that they were very satisfied with the service provided by the home, and that their family shared the same opinion. It was noted that visitors speak to all of the residents at the home, not just their own relative. This provides social contact for those residents that do not have regular visitors. Information about advocacy services is displayed in the home; this enables people to access these services without having to ask someone for the information and promotes privacy and independence. Discussion with the registered manager on the day of the site visit evidenced that appropriate advice and assistance is sought for residents when personal issues are identified. The social care professionals we spoke to us told us that they had visited at meal times and had noted that the food provided by the home had improved. Care plans record a person’s likes and dislikes regarding food and the registered manager told us that the cook has a record of this information in the kitchen. We noted that there is a varied menu in place and that this includes a choice of meal at every mealtime. Diabetic diets are catered for; two of the residents have diabetes and we were told that all puddings prepared by the cook are ‘low sugar’ versions so that none of the residents are made to feel different. We observed that people were offered fruit juice to have with their meal, and that ample drinks were made available throughout the day. We noted that people were allowed to take their time when eating their meals and that staff offered appropriate assistance where needed. Staff told us that some residents require a lot of encouragement to ensure that they eat enough, and we observed that this was done appropriately by staff. Meal times are not hurried and residents are encouraged to see this as ‘social’ time. Birchdale DS0000062588.V373104.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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and others know how to use the complaints procedure and residents say that staff listen to them. Residents will be further protected from the risk of harm when all staff have completed training on safeguarding adults. EVIDENCE: There are appropriate complaints policies and procedures in place, and the complaints procedure is displayed in various areas of the home. The organisation has employed a new general manager and they are in the process of developing a new complaints procedure; this will include the use of a complaints log and a comments book. Currently, all complaints and concerns are recorded together but it is felt that formal complaints and ‘grumbles’ from residents should be recorded separately. The complaints book records complaints from residents about the meat being tough on a particular lunchtime, and includes a record of the action taken to rectify this. It is intended that the new complaints procedure will be added to the Statement of Purpose and Service User’s Guide, and that all residents will be given an updated version of the Service User’s Guide. The relative that we spoke to on the day of the site visit told us that they had never had any need to complain. However, they were certain that the manager and staff would listen to them and take appropriate action if they had any concerns or complaints. No formal Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 17 complaints have been made directly to the home or to the CSCI since the last key inspection. There have been no recorded allegations or incidents of abuse at the home since the last key inspection. There are appropriate policies and procedures in place that are designed to safeguard vulnerable people from all types of abuse. The registered manager has attended the ‘Manager’s Awareness’ training course on safeguarding and is due to attend the ‘Training for Trainers’ course in November 2008. She then intends to provide training for the whole staff group. Some staff have previously attended training on adult protection but this should be updated to ensure that all staff have up to date knowledge on this topic. We saw an incident report in a resident’s care plan that recorded an assault or attempted assault between two residents. This was dealt with by the manager, who talked to both people concerned following the incident and checked that they were fine. Neither was adversely affected by the event. However, this should have been referred to the local authority under safeguarding protocols so that an independent decision could be reached about the level of harm or risk to the residents concerned, and whether any further action needed to be taken. This was discussed with the manager, who understood the reasons for our concern and agreed that a referral would be made to the local authority in the future. Birchdale DS0000062588.V373104.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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean and well furnished but some rooms need to be upgraded to provide hygienic and safe surroundings for residents. The laundry and food storage facilities would be improved if they were relocated; this would increase good hygiene practice and be more convenient. EVIDENCE: Communal areas of the home were seen to be clean and tidy on the day of this site visit, and we noted that bedrooms had been reorganised so that the rooms in use contained good quality furniture, and that all bedrooms (apart from one or two exceptions in rooms not currently in use) now included the furniture that is required to provide safe and comfortable accommodation. Bedrooms Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 19 were clean and hygienic, apart from two bedrooms that had carpets that needed replacing – one due to a strong odour and ‘uneven’ surface, and the other because it was worn. The vanity unit in one of these bedrooms also needs to be replaced, as it is shabby and difficult to maintain in a hygienic condition. Communal areas of the home are no longer used to store mobility equipment such as hoists and mobility scooters. These are currently stored in empty bedrooms; consideration should be given to where these will be stored when there are no empty bedrooms. A cupboard in a residents bedroom that was previously used for general storage is no longer in use and has been locked to make it safe for the resident accommodated in that bedroom. There is no maintenance programme in place but it is evident that more effort has been made to maintain the premises in a safe condition. A maintenance programme would evidence that consideration is being given to the ongoing refurbishment and redecoration of the premises, and provision of safe and suitable equipment. This is also an indication that the home is a viable business. The conservatory has been in use during warmer periods, but it is currently too cold to be used by residents. The heater in use is small and needs to be replaced by a more efficient heater so that the room can be used throughout the year. This would allow residents to continue to view the garden; they cannot see the garden from the either of the lounges or the dining room and some of the residents have enjoyed feeding and watching the birds. Food and cleaning materials continue to be stored in an out building. This still requires updating so that it is easy to maintain in a clean and hygienic condition. We noted that, on one occasion during the day, the storage area was left unlocked. We discussed with the manager the possibility of food being stored in the current laundry room (which is close to the kitchen and within the main building) and the laundry room being relocated into the out building. The current laundry room is very small and does not include a hand washbasin to enable staff to wash their hands when they have been handling soiled linen, or a washbasin for sluicing. The out building already has a sink unit so it would seem more appropriate for the laundry room to be located there. The laundry room contains one washing machine (that does not have a sluice facility) and a tumble dryer; this is adequate for the current number of residents. We observed that staff used good hygiene practices throughout the day, including the use of protective clothing and disinfectant gel. All care and domestic staff are currently undertaking training on infection control; this protects residents and staff from the risk of cross infection. Birchdale DS0000062588.V373104.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care staff receive induction and on-going training to ensure that they have the knowledge and skills to care for the residents living at the home, and appropriate qualifications are held. EVIDENCE: There is a staff rota in place that records the staff on duty each day, including domestic and catering staff; the role of each member of staff is identified on the rota. There are two care staff on duty throughout the day, with the manager working day time hours Monday to Friday in addition to this. There is one ‘waking’ care worker and one ‘sleeping’ care worker during the night. A cook is employed on six days per week and a domestic is employed on five days per week. One of the carers helps to prepare the lunch on a Sunday; the cook does some preparation the previous day to make this task easier for the staff on duty. The rota also records the name of the manager who is ‘on call’ outside of normal working hours. There are currently six care staff working at the home. The training and development plan evidences that four of these staff have achieved NVQ Level 2 in Care, and that two of them have also achieved NVQ Level 3. A further two Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 21 carers have commenced this award. The requirement for 50 of care staff to have achieved this award is therefore met. On previous occasions we have been concerned that staff have commenced work at the home prior to satisfactory recruitment checks being in place. There have been no new staff employed since the last key inspection so it was not possible to assess any improvement on this occasion. However, we did ask the manager numerous questions about the home’s policies, procedures and practices and it is evident that the manager understands the need to ensure that all safety checks are in place prior to people commencing work. This includes thoroughly checking a person’s previous employment history and exploring any gaps, and obtaining a reference from the applicant’s most recent employer. We looked at the new application form devised by the organisation and noted that it now asks applicants to declare whether or not they have any criminal convictions. The organisation have now appointed a company trainer and a training and development plan has been produced. This records that all staff have completed Induction training, although there is no evidence that this meets Skills for Care requirements. All new staff should complete Induction training that meets these requirements within six weeks of commencing work at the home. This training ‘cross references’ to NVQ training and therefore assists care staff with achieving their award. The training and development plan records the training achievements of staff and training that has been arranged for staff. Records evidence that most staff have undertaken moving and handling, food hygiene, dementia care, palliative care, challenging behaviour and adult protection training during 2008. All staff, apart from the cook, are currently undertaking training on infection control. There are also individual records of training achievements in staff files. Birchdale DS0000062588.V373104.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 and 38. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, welfare and safety of residents and others are protected to some extent by the systems in place; more care must be taken to ensure that all servicing of equipment is up to date. Quality assurance systems should be fully operational so that residents and others are able to affect the way in which the home is operated. EVIDENCE: Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 23 There is a new manager in post who has evidenced that she has the skills to manage the home. She is due to commence the Registered Manager’s award and keeps her practice up to date by attending in-house training with the rest of the staff group. As previously mentioned, she has recently attended the manager’s course on safeguarding adults and is due to attend the Training for Trainers course that will enable her to cascade this training to the rest of the staff. We observed on the day of the site visit that staff and the manager worked well as a team, and staff told us that they felt that they were all working well together to provide good care for the residents. An improvement plan was forwarded to the Commission for Social Care Inspection following the key inspection of the home in May 2008. The manager had a copy of the improvement plan on the office notice board and was recording when each action point had been achieved. A copy of the electrical installation certificate was also forwarded to the Commission as requested; this was received in September 2008. The manager has made efforts to use the quality assurance systems in place at the home. Staff meet together as a team each morning to have a ‘handover’ and there are plans to hold formal meetings for residents and staff. Staff had previously not had formal supervision with a manager but the current manager had met with each member of staff once to hold a supervision meeting and it is planned that these will be held every two months. A survey about the food provided by the home is planned. The manager needs to continue with these plans to ensure that there is continuous self-monitoring and to enable residents and others to affect the way in which the home is operated. Information gained from surveys, audits and meetings with residents and others should be collated, analysed and published, and this information should be used to inform plans for the forthcoming year. Policies, procedures and practices are reviewed on a regular basis. We examined the records for monies held on behalf of residents and crosschecked these with actual monies held - both were found to be accurate. Receipts are obtained for any purchases made on behalf of residents, and when they have the services of a hairdresser or chiropodist. We recommend that a receipt be given to relatives when they hand money to staff for residents for safekeeping and when money is handed to residents, to protect all parties concerned. We examined health and safety documentation for appliances, equipment and services at the home. These were all up to date, apart from the annual test of the fire alarm system. The manager was not aware that this was overdue and an immediate requirement notice was left at the home in respect of this breach of regulation. The manager informed us that this work had been carried out by a contractor on the 25th November 2008. Water temperatures at outlets accessible to residents are checked on a regular basis; records evidenced that temperatures were too high on one occasion but that a plumber had been Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 24 contacted and had attended the home to correct the fault. Room temperatures are also checked on a weekly basis. In-house weekly fire tests are undertaken but there has not been a fire drill for some time; the manager agreed to reinstate these. There is an accident book in use at the home; we noted that the CSCI are not always being informed of accidents and incidents at the home under Regulation 37 of the Care Homes Regulations 2001; the manager was reminded that the Commission should be informed of any accidents that require medical intervention. As previously recorded, the outbuilding used to store cleaning materials should be locked at all times to protect residents from the risk of harm. The training and development plan evidences that staff have recently undertaken training on health and safety and food hygiene and that they are all currently undertaking training on infection control. Birchdale DS0000062588.V373104.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 X 2 X X 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 1 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Yes Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Timescale for action Insulin and other medication that 31/12/08 requires storage at a low temperature must be stored securely and at the correct temperature; a separate medication fridge is the preferred solution. Previous timescale not met. Any allegations or incidents of 10/11/08 abuse must be referred to Social Services under safeguarding protocols. Previous timescale not met. Residents and other stakeholders 31/01/09 must be consulted about the quality of the service provided by the home via the use of quality assurance systems. 17/11/08 The fire alarm system must be serviced on a regular basis to ensure that residents and others are protected by a fully operational fire safety system. An immediate requirement notice was left at the home in respect of this breach of regulation. (The manager notified us that the fire alarm system was serviced on 25/11/08). Requirement 2. OP18 13 3. OP33 16 4. OP38 23 Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 27 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. 2. 3. Refer to Standard OP8 OP38 OP18 OP19 Good Practice Recommendations A risk assessment should be completed in respect of the use of bed rails and regular safety checks should take place. All staff should have training or refresher training on safeguarding adults from abuse to ensure that they have up to date knowledge on this topic. There should be a maintenance programme in place that records all plans for refurbishment, replacement of equipment etc. to evidence financial viability and forward planning. The storage area for food and cleaning materials should be locked at all times. This area needs to be upgraded so that it can be maintained in a clean and tidy order. Consideration should be given to moving the food storage area into the main building to promote good hygiene practices, and relocating the laundry room into the outbuilding, where there is a sink unit that would allow staff to wash their hands after handling soiled laundry. All staff should receive induction training that meets Skills for Care guidelines within 6 weeks of commencing work. The manager should apply to the Commission for Social Care Inspection for registration in due course, and should continue with plans to enrol on the Registered Manager’s award. Staff meetings and resident meetings should be held as part of quality assurance systems to enable residents and others to affect the way in which the home is operated. The outcome of any surveys, audits or meetings should be collated, analysed and published, and used to create an annual development plan. Fire drills should take place to ensure that staff and residents know how to react in the event of an emergency. The commission should be informed of any accidents or incidents that require medical intervention via Regulation 37 notifications. 4. 5. OP26 OP26 6. 7. OP30 OP31 8. OP33 9. 10. OP38 OP38 Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Birchdale DS0000062588.V373104.R01.S.doc Version 5.2 Page 29 - 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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