Inspection on 22/05/08 for Birchdale

This inspection was carried out on 22nd May 2008.

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

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 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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Birchdale 6 Tennyson Avenue Bridlington East Yorkshire YO15 2ES Lead Inspector Diane Wilkinson Key Unannounced Inspection 22nd May 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.V366520.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.V366520.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. Ms Julie Dawn Pearson Care Home 25 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (25) of places Birchdale DS0000062588.V366520.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 and Dementia - Code DE The maximum number of service users who can be accommodated is: 25 28th November 2007 2. Date of last inspection Brief Description of the Service: Birchdale is a care home that is owned by a small private company. It is situated in a period property 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. It is registered to provide care for a maximum of 25 older people, including those with dementia. Private accommodation is provided over three floors in nineteen single rooms and three shared en-suite rooms, with access via a passenger lift to the upper floors. 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 care supervisor told us that fees charged are between £300.00 and £355.00 per week, and that chiropody, hairdressing, transport and outings/holidays are not included in this fee. Birchdale DS0000062588.V366520.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 0 star. This means the people who use this service experience poor 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 28th November 2007, including information gathered during a site visit to the home. The unannounced site visit was undertaken over one day; it began at 10.30 am and ended at 4.50 pm. On the day of the site visit we spoke with the care supervisor, the registered manager of another care home in the organisation and the staff on duty on a one to one basis, and chatted to residents. Inspection of the premises and close examination of a range of documentation, including four care plans, were also undertaken. In addition to this site visit, we visited the home on the 13th March 2008 to undertake a random inspection. This was as a result of issues raised during a safeguarding investigation undertaken by the local Social Services team. Some of the findings of the random inspection will be included in this inspection report. The manager submitted information about the service in advance of the site visit by completing and returning an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service, as well as giving us some numerical information about the service. Survey forms were sent out as part of the inspection; none were returned by residents and four were returned by staff. Comments from returned surveys and from discussions with residents, staff and others varied, such as, ‘staff give good care to service users’ and ‘I feel that the residents are lacking fresh air. I have been here for several months and in that time they have never had an outing’. Comments from surveys and from discussions on the day of the site visit will be included, anonymously, throughout the report. Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The recording on medication administration records has improved and now provide an accurate record of medication administered on a daily basis. Staff have very recently undertaken accredited medications training to ensure that they have the skills required to administer medication safely. The ramp used at the entrance to one bedroom has been replaced by steps and a handrail, and this bedroom is now only used by people who are mobile enough to use the steps. Residents and staff are now asked to complete satisfaction surveys and the outcome of some of these have been collated and published. Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Birchdale DS0000062588.V366520.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.V366520.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 poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are usually assessed prior to their admission to the home but inappropriate admissions have been made. EVIDENCE: No new permanent residents have been admitted to the home since the random inspection on the 13th March 2008. One person was admitted to the home at the end of last year; there was a full needs assessment in place and this information had been used to develop an individual care plan. Staff told the inspector that this person had attended the home for respite care initially and had then decided to remain at the home. However, records at the home do not confirm that this person was visited at home as part of the assessment process prior to their admission, or that they had initially had respite care. Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 10 There was a new respite service user at the home on the day of the site visit. This person was normally a resident at another home belonging to the organisation. There was a care plan in place that had been completed at the other home for staff to follow, and staff were completing daily records in respect of this person. We were concerned about the assessment process that had taken place prior to this respite stay being agreed, as the person concerned has very different needs to the residents already accommodated at the home. Staff at the home have the skills and experience to work with the residents normally residing at the home, but they have no experience of working with people with mental health problems. The registered provider was contacted following the day of the site visit and he agreed to write to the CSCI to explain the decision making process about this admission. One member of staff told us that they are told about a person’s needs, likes and dislikes when they are first admitted, but another member of staff said that ‘management bring residents in without their full background history for us to work with’. Birchdale DS0000062588.V366520.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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning documentation evidences that health care needs are met in a way that respects a person’s privacy and dignity. EVIDENCE: We examined the care plans for three of the ten permanent residents. All had a full needs assessment in place (although some were not dated) and an individual care plan. Daily records are a good record of how someone has spent their day and the support provided by staff. Key workers make a weekly record of key events for that week and monthly reviews of the care plan are taking place, although some of these had lapsed. Care plans have been signed by residents to agree to the content when they have the ability to do so. Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 12 There are pro formas in place for the completion of general risk assessments but some of these had not been completed. Some more specific risk assessments had been completed for individual residents, such as the use of mobility scooters. The care plans seen by us on the day of the site visit did not include any information about formal reviews of care plans, although the inspector has been told by the local authority that annual reviews do take place for the residents that they place at the home. Some care plans do not include a photograph of the resident; this is needed to assist new staff with identifying residents, and to assist the emergency services should someone go missing from the home. At the random inspection in March there were some concerns that health care issues were not being referred to appropriate people. At this inspection we found that records concerning a person’s involvement with health care professionals is good; information is recorded about all contact with GP’s, District Nurses and hospitals, including the reason for the contact. People are weighed monthly as part of nutritional screening and care plans include information on a person’s dietary requirements, including any likes/dislikes and allergies. One person had been visited by a dietician following concerns about low weight; the home were asked to complete a four day diet sheet for the dietician. Advice was given to staff about the type of foods that should be encouraged and the dietician was subsequently pleased with the person’s weight gain. We saw that equipment to promote continence care and tissue viability had been obtained for residents, including pressure care mattresses. Some residents have been issued with bed rails; we noted that risk assessments had not been completed for this provision and that there are no recorded checks on the safety of bed rails. We observed the administration of medication at lunchtime. Medication administration records (MAR) include a photograph of each resident to aid with identification. There were no gaps in recording and any changes to the information already recorded on the MAR sheet had been signed by two members of staff. When residents decline medication that is prescribed as ‘as required’, staff record this on the MAR sheet. We noted at the time of this inspection that the medication procedure used at the home is very brief. We saw the medication procedure used by the ‘sister’ home, which was more detailed, and advised that this should be adopted at Birchdale; staff agreed to this. Controlled drugs were found to be stored safely. Records were checked and found to be accurate, and they balanced with the stock of medication held. The temperature of the medication trolley is taken daily to ensure that Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 13 medication is stored at under 25°C. We were told by staff that they are in the process of purchasing a medication fridge so that they will be able to store medication that needs to be stored in a cool environment safely; this is currently stored in the fridge in the kitchen. We examined the records for medication returned to the Pharmacist and noted that this was satisfactory. There is no excess stock held at the home. The care supervisor told us that she has very recently completed accredited medications training with a local pharmacist, along with four other members of staff. The care supervisor said that she is not yet administering medication, as she understood that she needed to obtain her certificate before she could do so. We advised that she should administer medication whilst been observed by the registered manager of their sister home on two occasions. If she is considered to be competent, she could start to administer medication at the home even if her certificate of achievement has not been received. There are plans in place for remaining care staff that may be asked to administer medication to undertake accredited training. There were no sample signatures for the staff administering medication to enable records to be checked for authenticity. We noted that staff use the preferred term of address for residents and that they observe a person’s right to privacy. People were seen to be wearing their own clothes and were dressed to suit their own choice and lifestyle. Birchdale DS0000062588.V366520.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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to make choices about their day-to-day lives but would benefit from opportunities to take part in social activities and individual interests. Meal provision at the home is good. EVIDENCE: Care plans include information on a person’s life history and previous lifestyle, and we observed that people are supported to spend their day as chosen by them. People are able to spend the day or part of the day in their own room or in one of the lounges, and some people go out during the day unaccompanied by staff. Daily records include information on any activities undertaken, visits out of the home, any visitors seen and food/fluid intake. We noted on the day of the site visit that staff spend one to one time with residents and encourage them to take part in social activities when time allows. Staff told us that they arranged various activities over the Easter Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 15 period, including an egg rolling contest. Staffing levels do not currently allow staff to spend time taking residents out and staff told us that they would like to have the time to do this. A member of staff said in a survey, ‘I have only taken my resident out once in the five months I have been his key worker’, and another said, ‘I feel that these residents are lacking fresh air. I have been here for several months and in that time they have never had an outing’. Visitors to the home are made welcome and people are supported to remain in contact with relatives and friends. People are able to bring some of their personal possessions into the home and we saw evidence that people are able to exercise personal autonomy and choice. There is currently no information available about advocacy services; this should be displayed in the home to enable residents and others to access services without having to ask for assistance. A new cook has just started to work at the home. There is a menu in operation for breakfast, lunch, tea and supper and residents confirmed that there is a choice of meal on offer. We were told that the cook asks the residents on a daily basis about their choices for that day. Vegetarian options are always available on the menu and diabetic diets are catered for. Residents told us that they are happy with the meals provided and the choices on offer, and staff told us that there has been an improvement on meal provision since the new cook was employed. We saw that staff offer appropriate assistance with eating and drinking, and that ample drinks are provided at meal times and throughout the day. Lunchtime was unhurried and residents were able to eat their meal at their own pace; the dining room provides a pleasant environment for residents to take their meals. Birchdale DS0000062588.V366520.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. Information is provided about how to make a complaint and residents and others know who to speak to if they have any concerns, but we are not confident that complaints are dealt with effectively. Staff have had minimal training on safeguarding adults protocols and we are concerned that the appropriate people may not be informed should an allegation or incident of abuse occur. EVIDENCE: There is a satisfactory complaints procedure in place and this is displayed in the entrance hall. We examined the complaints log and the comments book held at the home. The complaints log recorded several complaints from residents about such issues as meal provision and missing money, and an outcome had also been recorded. There is no record of whether complainants are satisfied with the outcome of the investigation. Some complaints that had previously been brought to the attention of the CSCI were not recorded in the complaints log. These may have been recorded Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 17 elsewhere, for example, in records reporting safeguarding allegations. These records could not be found on the day of this site visit. There were no records of staff induction training available on the day of this site visit. It was therefore not possible to determine if staff undertake training on safeguarding when they first start to work at the home. Discussions with staff indicate that induction training consists of an introduction to the homes residents, environment and basic health and safety information rather than training on core topics such as moving and handling, food hygiene, infection control and safeguarding. Staff told us that they have a copy of the Hull and East Riding Vulnerable Adults procedures and an in-house policy that was dated November 2001 was located, but it was unclear which policies and procedures staff were using. The care supervisor told us that she is due to attend Manager’s awareness training on the 23rd June; she then hopes to be in a position to offer in-house training to staff. Some staff have undertaken training on safeguarding adults as part of their National Vocational Qualification (NVQ) training. Staff told us in surveys that they know what to do if a resident or their relative has any concerns about the home. However, in previous months the registered manager has not always followed local safeguarding protocols and this has resulted in uncertainty about whether the appropriate people would be alerted if a safeguarding allegation were to be made. Birchdale DS0000062588.V366520.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, 20, 22, 24 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. Communal and private areas of the home were clean and hygienic on the day of the site visit. EVIDENCE: On the day of the site visit we found the communal rooms to be clean and comfortable; the main lounge is light and airy and the ‘quiet’ lounge is available should people wish to meet with visitors in private or spend some time on their own. A cupboard has been built in the ‘quiet’ lounge to enclose the medication trolley and this does not intrude on the resident’s living space. Furnishings in communal rooms are domestic in character and of good quality. Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 19 A mobility scooter is still stored in one of the lounges and alternative storage arrangements must be found. Bedroom accommodation is adequate but we continue to feel that some of the more pleasant bedrooms are being reserved for people who have respite care at the home rather than being offered to permanent residents. Most bedrooms now include all of the furniture that is required, although the registered person should check that all bedrooms to be occupied include drawers, hanging space, overhead/bedside lighting and comfortable seating for two people. Bedroom doors should be lockable so that residents can be offered their own key. The conservatory has now been completed but access to this is not easy for some residents. The surrounding garden is unattractive and poorly maintained and does not currently give residents an inviting area to look at or use. The home could be missing an opportunity for residents to take part in gardening/outdoor activities. There is no maintenance plan in place although the home was generally well maintained on the day of this site visit. There have been some concerns during the last few months about breakdowns at the home; the smoke detectors were not working on the ground floor and a water tank leaked causing damage to a bedroom. The local fire department loaned the home some domestic smoke detectors and fire officers fitted the smoke alarms for staff. On the day of this site visit we were told that the home’s smoke detectors are now working. We checked that the call system was working, as this has also been an area of concern. This was working satisfactorily but we noted that staff have to come to the staff room to look at the control panel to see who is ringing the call bell; this could create a delay in them dealing with an emergency. The home provides specialist equipment to maximise residents’ independence, and the ramp into a bedroom that caused us concern previously has been removed. This has been replaced by steps and handrails, and is only used by respite residents who are mobile enough to use stairs. However, there is a cupboard in this bedroom that is used for the storage of continence products for all residents, and the cupboard door is not locked. These should be stored elsewhere and the cupboard door should be locked – it is not safe to be used by residents. At the time of this visit and at the random inspection in March we observed that the outbuilding used for the storage of food and cleaning materials is in need of cleaning and upgrading. It was not locked at the time of either of these inspections and could have been accessed by residents, posing a risk to their health by them mistaking cleaning materials for food or drink. The equipment provided in the laundry room is satisfactory and disinfectant gel is now available for staff to use as they leave the laundry room. There is a Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 20 domestic assistant in post who works for five or six days per week; this allows care staff to concentrate on caring duties and reduces the risk of cross infection. The home was clean and hygienic on the day of the site visit. At the last inspection we were told by the registered manager that two staff had completed training on infection control; at this inspection we were told that another seven members of staff are undertaking this training via a distance learning course. Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 21 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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty to provide personal care but there is a lack of time for social interaction. Improvements need to be made to recruitment practices and to induction training to ensure the safety of residents. EVIDENCE: There is a satisfactory staff rota in place that records the role of each member of staff. The rota records that there is a domestic assistant on duty for 5 or 6 days per week, and a cook on duty every day. This enables care staff to concentrate on personal care duties. The hours worked by the registered manager are not recorded on the rota but the manager to be contacted outside normal working hours is recorded. It is good practice for the hours worked by the registered manager to be recorded so that staff can inform people when she will be available. A member of staff told us in a survey, ‘staff give good care to service users’ although another said, ‘I feel there should be three carers on many a time so it would be possible to take residents out’. Five of the twelve care staff have achieved NVQ Level 2 in Care, and three of these have also achieved NVQ Level 3 in Care. A further three care staff are Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 22 working towards NVQ Level 2 in Care so the requirement for 50 of care staff to have completed this award should be achieved in due course. Recruitment practices at the home have previously been a cause for concern. On the day of this site visit the recruitment records for two new members of staff were examined. The application forms included details of the applicant’s most recent employment but in one instance a reference was not obtained from the most recent employer; as this was a care provider, this would have been the most appropriate person to contact. There is no evidence that any gaps in employment are explored. The application form has not been altered since the last inspection and there continues to be no declaration by applicants about their criminal convictions. Two written references and a POVA (Protection of Vulnerable Adults) first check were obtained prior to the person commencing work at the home, and a satisfactory CRB check was subsequently received. Copies of the applicants training certificates were obtained and application forms included information about a person’s previous experience and training. We noted that a record is kept of the questions asked at the employment interview and of the applicant’s responses. There is no training and development plan in place at the home, although there are some training records in individual staff files. There is no evidence that staff undertake induction training that meets skills for care specifications. The records seen on the day of the site visit evidence that staff that started work at the home in April had not yet commenced induction training. Staff told us that it is normal practice for new staff to ‘shadow’ experienced staff when they first start work at the home, and records support this. There should be a training and development plan in place that records the training achievements and training needs of staff; the date that training is completed should be included so that the need for refresher training is clearly identified. The care supervisor told us that various training courses have been attended by staff during the past few months; nine staff attended fire safety training in November 2007, half of the care staff group did moving and handling training last year and five staff have recently completed accredited medications training. Seven staff are currently undertaking training on infection control. The care supervisor has booked a place on safeguarding adults training for managers, and plans to cascade this training to the full staff group. We noted that staff are given an employee handbook when they start work at the home. This contains some useful information but does not include information on safeguarding adults, complaints, moving and handling or infection control. Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 23 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 poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is not being managed in a way that promotes teamwork, and the safety and security of residents and staff. The quality assurance system needs to expand to include the completion of an annual development plan. EVIDENCE: The registered manager is currently undertaking the NVQ Level 4 Registered Manager’s award; she was on sick leave on the day of this site visit so we were Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 24 not able to speak to her. We were told that the care supervisor is currently ‘in charge’ and she told us that she is being supported by staff at the head office and by the registered manager of their ‘sister’ home. We have not been informed of this by the registered provider. Staff told us in surveys about their concerns regarding management arrangements at the home. They told us that the registered manager does not work well as part of a team, and that they do not feel supported by her. One person said, ‘staff no longer trust the manager as she has put the blame on staff for things which she has done, and put the blame on head office – we cannot believe anything’ and another said, ‘we as a staff group feel that this is a good home and could work well if we had more support from management’. The local authority Social Services team have recently informed us that they have temporarily stopped making placements at the home due to their lack of confidence in the management arrangements at the home, especially in respect of the handling of complaints and safeguarding allegations. On the day of this site visit staff were seen to be working well as a team and were spending one to one time with residents. The care supervisor and registered manager from their ‘sister’ home were working together to arrange a variety of training opportunities for care staff to ensure that their practice was up to date. Residents meetings and staff meetings are held at the home – the most recent staff meeting was held on the 3rd March 2008 and we saw documentation recording that staff were asked to pass on any comments for discussion if they were unable to attend. Satisfaction surveys were sent to relatives in September 2007 and the outcome of these was published in December 2007. Residents surveys were distributed in February 2008 but the outcome of these has not yet been collated or published. The quality assurance system at the home should be expanded to include the regular review of policies and procedures and the production of an annual development plan. The registered provider is undertaking unannounced visits to the home under Regulation 26 of the Care Homes Regulations 2001. Following the key inspection in November 2007 we requested that the registered provider produce an improvement plan and return it to us within one month. In the inspection report of the random inspection in March 2008 the registered provider was reminded that this had not been received by the CSCI. Monies held on behalf of residents and associated records were checked by the inspector; these were found to be accurate. The records held include details of monies received, monies paid out and a running total, and receipts are obtained for any financial transactions carried out. Some residents are given money by relatives and they are then responsible for holding these monies. Residents are provided with a lockable storage facility in their bedrooms so Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 25 that they can hold money safely. We were told that, although residents do not have access to their monies at all times, there is now sufficient petty cash held at the home to enable residents to be loaned money until their own money can be accessed. There is a fire risk assessment in place and records show that all staff undertook fire safety training on the 6th November 2007. There is a gas safety record dated June 2007 and the fire alarm system was checked by a qualified person in July 2007. In-house weekly fire tests are been done consistently; this offers some protection to residents and staff regarding the risk of fire. The handyman undertakes room temperature checks, checks on the call system and water temperature checks at all outlets accessible to residents; associated records evidence that water temperatures are controlled to reduce the risk of scalding. No electrical wiring certificate has been forwarded to the CSCI as required at previous inspections. Evidence that electrical wiring within the home is safe must be forwarded to the CSCI within the required timescale; failure to do so may result in enforcement action. The inspector saw evidence that the passenger lift, bath hoists and the mobility hoist were serviced in September 2007. Accidents that occur at the home are recorded appropriately, and we are being informed of accidents and incidents at the home under Regulation 37 of the Care Homes Regulations 2001. Cleaning materials are now stored in an outbuilding but this is not kept locked at all times – see Environment. As previously recorded, there is little information available to evidence that staff have undertaken appropriate health and safety training, either at the time of induction training or on an on-going basis. Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 26 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 X 3 X 2 X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 2 Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 27 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 OP3 Regulation 14 Requirement Only residents whose assessed needs can be met by staff working at the home should be offered a placement. There must be a sample of staff signatures available to enable medication records to be checked for authenticity. Previous timescales not met. Timescale for action 22/05/08 2. OP9 13 22/05/08 3. OP9 13 Insulin and other medication that 22/05/08 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. All complaints must be investigated using the home’s complaints procedure and must be recorded in the complaints log. Previous timescale not met. 22/05/08 4. OP16 22 Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 28 5. OP18 13 Any allegations or incidents of abuse must be referred to Social Services under safeguarding protocols. Staff and the registered manager must attend training courses on safeguarding adults to ensure that they are fully aware of the procedures that should be followed in the event of an allegation being made, and that they are able to identify unacceptable practice. Previous timescale not met. Application forms for employment must ask for information about any criminal convictions held by applicants. Previous timescale not met. One reference must be obtained from an applicant’s most recent employer. Any gaps in employment must be explored by the registered person. Previous timescales not met. All staff must receive induction training that meets Skills for Care guidelines within 6 weeks of their appointment. Previous timescales not met. The training and development plan must be updated, and a copy must be forwarded to the CSCI. Previous timescales not met. The home must be managed by someone who has the qualifications, skills and experience necessary for managing a care home. 22/05/08 6. OP29 19 22/05/08 7. OP29 19 22/05/08 8. OP30 18 22/05/08 9. OP30 18 22/05/08 10 OP31 9 28/07/08 Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 29 11 OP33 24A When an improvement plan is requested by the CSCI, it must be provided to us within one month of receipt of the request. Timescale of 08/02/08 not met. 22/05/08 12 OP38 13 Cleaning materials must be 22/05/08 stored in a locked cupboard at all times. Previous timescales not met. An electrical wiring safety certificate must be available for examination at the home. Previous timescales not met. 22/05/08 13 OP38 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations There should be evidence that care plans have been formally reviewed to ensure that they reflect the current needs of residents. Care plans should include a photograph of the residents to assist new staff with identification and to assist the emergency services should a resident be missing from the home. Residents should be given opportunities for stimulation through leisure and recreational activities inside and outside of the home. Information about advocacy should be made available for residents and others. The garden should be made pleasant for residents to view and use. 2. OP7 3. OP12 4. 5. OP14 OP19 Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 30 6. 7. OP19 OP19 Alternative storage arrangements should be found for large pieces of equipment, such as mobility scooters. There should be a maintenance programme in place that records all plans for refurbishment, replacement of equipment etc. to evidence financial viability and financial planning. The storage cupboard in one bedroom should not be used and should be locked at all times. The storage area for food and cleaning materials should be locked at all times. This area needs to be maintained in a clean and tidy order to promote good hygiene standards. The hours worked by the registered manager should be recorded on the staff rota so that residents, staff and others know when she will be next available. The quality assurance system should be expanded to include the completion of an annual development plan and a regular review of policies and procedures. Bedrooms should include all of the furniture and fittings to make the room safe and habitable. Bedrooms doors should be lockable and residents should be offered a key. A risk assessment should be completed in respect of the use of bed rails and regular safety checks should take place. 8. 9. OP19 OP26 OP38 OP27 10 11 OP33 12 13 14 OP24 OP24 OP38 OP8 Birchdale DS0000062588.V366520.R01.S.doc Version 5.2 Page 31 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.V366520.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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