Inspection on 21/07/06 for Birchdale

This inspection was carried out on 21st July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Birchdale 10/11/08

Birchdale 22/05/08

Birchdale 28/11/07

Birchdale 04/07/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Birchdale 6 Tennyson Avenue Bridlington East Yorkshire YO15 2ES Lead Inspector Karen Ritson Key Unannounced Inspection 21st July 2006 09:30 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.V301950.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.V301950.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) 01274 498050 01274 497352 Pennine Care Services Ltd. Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25) of places Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of service users in categories OP and DE(E) who may be admitted for respite care is limited to a maximum of four (4) at any one time. 18th October 2005 Date of last inspection Brief Description of the Service: Birchdale is a period house, situated in Bridlington town centre. The home is in close proximity to local amenities including transport, shops, health care and leisure facilities. It is registered to provide care for a maximum of 25 older people, some of whom have dementia. There are eighteen single and three double en suite rooms on three floors with access by a passenger lift to the upper floors. At present the home has twelve residents. The service users have the choice of two lounges. A small courtyard style garden is located at the rear of the property, which has been made accessible to service users. Wheelchair access to the home is provided via a permanent ramp to the main entrance. The home has a statement of purpose, service user guide and a brochure, which provide information about the scope and nature of the care and facilities on offer. These, with CSCI reports, are available on request at the home. The fees charged are between £286.00 and £333.30 per week. Chiropody, hairdressing taxis and outings are not included in this fee and these are charged at cost. This information was provided to CSCI on 30/05/07. Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection for this service took 14 hours. This includes time spent gathering information and examining documentation before and after a site visit and in writing the report. The site visit took place on 21st and 25th of July 2006. Information for this inspection was gathered from the following: • A tour of the premises • Observations of care throughout the site visit days. • Speaking with service users, and visiting professionals. • Case tracking three service users on the site visit days. • Reading comment cards from health care professionals and relatives. • Looking at information provided by the manager in a pre inspection questionnaire. • Notifications sent to the commission from the home since the last inspection. • Examining policies, procedures and records kept at the home. All key standards were looked at during this inspection. The acting manager was present throughout the day of the site visit. An application to CSCI for registration as manager is due to be submitted. What the service does well: What has improved since the last inspection? Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 6 The acting manager has begun to update all care plans and has put in place a regular system of review. This means that the care received by service users is better tailored to their individual needs. Staff say they are more contented in their role and feel better supported. There have been frequent changes of manager recently and the home has run without a registered manager for some time also. The appointment of the new manager has made a great difference in the confidence of staff and the quality of care received by service users. One member of staff said of the acting manager: ‘She has a very calming influence on the home.’ What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Prospective residents and their representatives have the information needed to choose a home, which will meet their needs. Service users needs are assessed and their contract clearly tells them about the service they will receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users receive a thorough assessment of care needs before admission. Observations of care showed that service users needs were well known to all staff. The manager and staff said service users and their relatives are encouraged to look around the home before admission and the home provides a statement of purpose, a brochure and service user guide to help people make a decision. The brochure is well produced and contains a resume of the service users guide. The home does not usually offer intermediate care. Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The health and personal care a resident receives is based on individual needs. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service EVIDENCE: Care plans are detailed. Each area of care is reviewed individually and risk assessments are included when necessary. All visits from health care professionals are recorded separately on file. Two relatives said they were very happy with the care given and felt the staff understood what was needed. One said: ‘They are very patient and kind.’ Medication is kept, given and recorded appropriately, with policies in place. Staff who handle medication have had training. Observations of care showed that service users are treated kindly with their privacy and dignity respected. Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Residents receive a healthy, varied diet which they enjoy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although the home is experiencing a shortage of staff, service users still have the correct staffing ratio and staff have time to talk with service users and to engage in activities. There have been recent visits to Sewerby Park and a small group of service users have visited the beach. On one of the site visit days the home was having an open afternoon where service users from another Pennine Care Home in Scarborough had called for lunch and musical entertainment. Many visitors attended this and were obviously enjoying the day. The social needs of each service user are highlighted within the care plan and staff are given the time to accompany individuals on walks or for other activities such as ball games, golf, dancing and sitting in the courtyard during the warmer weather. One relative said: ‘Staff take (my relative) out and she enjoys going into town.’ A visiting minister attends each month to offer a Communion service for service users and several choose to attend. Some of the service users go out to Church. Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 11 The manager said she was looking into tailoring activities to meet the needs of those service users with a dementia. Visitors are welcome at any time. All service users and relatives spoke highly of the meals on offer. Food preferences are recorded on file and service users have a choice of meal at each mealtime. Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents have access to an effective complaints procedure; their complaints are listened to and acted on. Service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure. Service users said they could speak with staff if there was a problem or they had a complaint and that they were confident they would be listened to and any concerns acted upon. Staff have received abuse awareness training. A complaint has been investigated internally regarding a member of staff recently. The matter had proceeded to an internal disciplinary hearing and the member of staff has been reinstated whilst working under supervision. The management of the home have followed its own procedure correctly and recording was up to date and clear with regard to the outcome of the investigation. The home has an equal opportunities policy and procedure. Service users said they felt well cared for in the home, none said they had ever had cause to complain or had ever felt unsafe. Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Service users live in a safe, wellmaintained and comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well decorated and homely. Service user rooms are decorated to their taste. Many rooms were personalised with pictures, photographs and items of service users own furniture. Regular weekly checks are carried out throughout the home as part of the ongoing quality assurance procedure. The environmental health and fire authority recommendations have been put into place. The laundry facilities meet the standard and are unchanged since the last inspection. Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Staff in the home are trained and in sufficient numbers to fulfil the aims of the home and meet the changing needs of residents. Service users needs however will be better met when all staff have received TOPSS induction training and all staff have a current CRB check. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three staff files were examined. Staff are well recruited with all documentation in place and satisfactory training is provided. The manager plans for all new staff to receive TOPSS induction and foundation training, however, she has yet to provide this training for all staff and was aware of the need to address this. Most staff have received foundation training and other relevant training for their role. Sufficient staff are on duty to allow service users to receive one to one attention when needed, however, there are staff vacancies and existing staff have been working extra hours to cover shifts. At least 50 of staff are trained to NVQ level 2. Staff have been recruited with CRB checks and two references obtained for each person. One member of staff however had been recruited with a CRB check from a previous employment. CRB checks are not portable from previous employment and the manager agreed that a CRB check would be applied for immediately in respect of this member of staff. Staff were observed speaking with service users and offering care in a kind and thoughtful way; they were approachable, and obviously understood each service users care needs. Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 15 Staff said they received good support from the home’s management and they felt this helped them to provide good care in an unhurried way. One service user said: ‘The staff are always cheerful.’ Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Although the acting manager is relatively new in post, service users are already benefiting from an open and supportive style of management. Service users views are sought but have yet to inform practice to any great extent. Service users welfare is protected by health and safety systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager has NVQ Level 3 in care and is studying for the registered managers award, which is nearing completion. She is about to submit her application for registration as manager with CSCI. She has also demonstrated her commitment to updating her training alongside her staff team. Staff said they received good support from the home’s manager. One said she was: ‘Very calm’ and that this helped provide a reassuring atmosphere within the home. Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 17 The home has an annual quality monitoring system, where the views of service users are canvassed. The manager plans to develop this further to include feedback from all other interested parties and will devise a method by which the results of the questionnaires may be made public and inform future practice. There is no formal annual development plan in place yet but the manager intends to address this in the coming year. Health and safety is protected and promoted through staff training, effective risk assessments, regular checks on water temperatures, fire fighting equipment, gas supply, and servicing of all equipment. The electrical wiring safety certificate had not yet been produced and is required to comply with regulations. Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 18 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 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP38 Regulation 12,13 Requirement An electrical wiring safety certificate must be available for examination at the home. Previous timescale not met. The manager must be registered with CSCI Timescale for action 01/09/06 2 3 4 OP31 OP30 OP33 8 19 16/24 01/11/06 5 OP29 18/19 All staff must receive induction 01/10/06 and foundation training to TOPSS guidelines. The quality assurance system 01/11/06 must be developed to include feedback from all interested parties, the results of which must be published and inform future practice. All staff must have a CRB check 01/09/06 prior to working unsupervised in the home. Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 20 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 Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Birchdale DS0000062588.V301950.R01.S.doc Version 5.2 Page 22 - 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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