Inspection on 04/07/07 for Birchdale

This inspection was carried out on 4th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Birchdale 6 Tennyson Avenue Bridlington East Yorkshire YO15 2ES Lead Inspector Diane Wilkinson Key Unannounced Inspection 4th July 2007 10:00 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.V345108.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.V345108.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 birchdale@pcslimited.net Pennine Care Services Ltd. vacant post 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.V345108.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. 21st July 2006 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 in eighteen single rooms and three shared en-suite rooms over three floors, with access via a passenger lift to the upper floors. Communal accommodation is provided in two lounges and a dining room, and there is a small courtyard style garden 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. 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 pre-inspection questionnaire records that fees charged are between £286.00 and £390.00 per week, and that chiropody, hairdressing, transport and outings/holidays are not included in this fee. Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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 21st July 2006, 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 10.00 am and ended at 4.30 pm. On the day of the site visit the inspector spoke with two residents and the manager on a one to one basis, and chatted to other service users and staff. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The manager submitted information about the service in advance of the site visit by completing and returning a pre-inspection questionnaire. Survey forms were sent out prior to the inspection; four were returned from staff, one was returned from a relative and two were returned from health and social care professionals. Comments from returned surveys and from discussions with service users, staff and others varied, such as, ‘the home support service users individual needs, particularly social needs’ and ‘the home has had money spent on it but it doesn’t seem to be moving forward’. Comments from surveys and from discussions on the day of the site visit will be included, anonymously, throughout the report. The inspector would like to thank service users, staff and the manager for their assistance on the day of the site visit, and to everyone who completed a survey. What the service does well: What has improved since the last inspection? Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 6 Some bedrooms are in the process of being refurbished. 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.V345108.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.V345108.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. 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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to their admission to the home and only admitted if it is considered that their assessed needs can be met. EVIDENCE: The inspector checked the care records for three service users, including those for a service user that was recently admitted to the home. It was observed that a thorough assessment of needs is completed for service users prior to their admission to the home. This assessment includes risk assessments for pressure care, nutrition, safety, moving and handling plus a risk assessment for the service user’s bedroom. Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 9 The examination of records and discussions with service users and staff evidenced that some service users have respite care at the home prior to considering permanent care. Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 10 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. The health and personal care needs of service users are met in a way that respects their privacy and dignity but some omissions in care records could result in their individual assessed care needs not being fully met. Medication practices at the home are not robust and do not fully protect the safety of service users. EVIDENCE: The inspector examined the care records of three service users. Some of the records included a photograph and others did not; a photograph is needed to assist new staff with identifying service users and to assist the emergency services should a service user become missing from the home. Care plans were based on the assessment undertaken by the home and, in some instances, community care assessments/care plans provided by care management. Care plans had been reviewed formally by care management, Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 11 and records evidenced that service users attended their review if they wished to do so. The inspector read in one care plan review that the home had not completed information prior to the review that had been requested by care management, and that there had been no care plan in place; there is now a care plan for this service user. There is no evidence that service users have been involved in the care planning process. A relative that returned a survey said that they are kept informed of important issues affecting their relative and that the care home meets the needs of their relative. All of the care plans examined by the inspector included written risk assessments in respect of the risk of falls and moving and handling. Some care plans had risk assessments for nutrition and pressure care, whilst others did not. Some service users had been weighed as part of nutritional screening but this was not consistent, and in one care plan two sets of weight records were in place, one in pounds and ounces and another in kilograms – this could lead to confusion for staff and does not assist nutritional screening. Staff record a daily account of the care provided to service users and this includes information about any visitors seen and any trips out of the home. Visits from health care professionals, including the reason for the visit and any outcome, are recorded in individual care plans. However, the inspector noted that this information had not always been cross-referenced to daily diary entries. Care plan records evidence that any concerns regarding pressure care are recorded and that continence care is promoted. A white shower chair was being stored in one of the lounges - the manager told the inspector that this was used to take one service user from the lounge to the bathroom; this is unsafe practice. The manager was advised that such chairs are not intended for this purpose and that a wheelchair should be obtained for the service user. The inspector observed the administration of medication by the manager on the day of the site visit. Service users were provided with a drink with which to take their medication and medication records were not signed until the manager had observed that medication had been taken. Medication administration records had been completed in a satisfactory manner apart from some omissions of recording when service users refuse medication or medication is not given. The medication trolley is attached to the wall in one of the lounges; this should be relocated to a safer area where the temperature of the environment can be monitored and to improve security. Controlled drugs are also stored in the same trolley (in a lockable cabinet within the trolley) and they should be stored elsewhere, i.e. in a more secure area of the home. There is a separate record for recording the administration of controlled drugs and this includes two staff signatures and a ‘running total’ of medication remaining. There is no separate fridge for the storage of medication that requires a cool temperature, such as Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 12 antibiotics. It is recommended that a separate fridge be provided for the storage of medication; temperatures would have to be taken and recorded on a daily basis. There was no evidence available on the day of the site visit to demonstrate that staff that administer medication have undertaken accredited training, and that sample signatures are held for these staff to enable administration records to be checked. The inspector observed that staff respected the privacy and dignity of service users. They used the service user’s preferred name, and knocked on doors before entering. The manager informed the inspector that staff are told about privacy and dignity as part of their induction training and when undertaking NVQ training; 80 of the staff group have achieved NVQ Level 2 in Care. Staff were seen to talk to service users sensitively regarding personal care needs and when offering assistance with eating and drinking. Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 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. Service users are supported to make choices about their day-to-day lives but would benefit from staff having more time to spend with them. Meal provision at the home is good with a choice of meal being provided at all mealtimes. EVIDENCE: In most instances, care plans record the previous lifestyle of service users, including leisure and social interests and likes and dislikes. Daily diary sheets record activities undertaken by service users, such as listening to music, sitting in the garden, watching TV and going out with friends. All staff that completed a survey reported that there are currently not enough staff on duty to enable activities to take place, either within or outside of the home. However, one care manager recorded, ‘the care staff and manager appear to support the service users needs, i.e. as regards social needs. Seem to have a good range of activities and if a service user likes to go out ensure they go out with a carer on a regular basis’. On the day of the site visit, one service user went out to visit a relative and another had a visitor; they played dominoes in the bedroom of the service user. Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 14 Staff recorded in surveys that their role as key worker included personal shopping, ensuring that clothes are in a good state of repair and gathering information to assist with social activities and interests. Key workers are expected to record a monthly summary of events, but in some instances, these were not consistent so care plans were not a full record of a person’s care package. Care plans included an ‘activities record’ but again, some recording was spasmodic. Discussion with service users evidenced that those service users that have friends and relatives are supported to remain in contact with them, and that their visitors are made welcome by staff at the home. There are no details about advocacy services available for services users and visitors; the manager agreed to obtain information to display in the home. Service users are able to make some choices, for example, where to spend their day and where to take their meals. Service users are encouraged to bring some of their personal items into the home. The inspector observed the serving of lunch on the day of the site visit; the meal provided looked appetising and service users told the inspector that they had enjoyed it. A member of staff recorded, ‘the menu is good and varied. Residents have a choice for breakfast, lunch and tea, and the presentation is good’. There was no menu on display; a menu would encourage service users to become involved in meal provision at the home and may encourage conversation. Most service users had their lunch in the dining room on the day of the site visit and they chatted to each other and to staff. The inspector noted that service users were offered appropriate assistance with eating and drinking, and observed that an ample supply of drinks was made available during the day. Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 15 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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information about how to make a complaint is provided but staff should ensure that this is fully understood by service users and others. There are appropriate policies and procedures in place on safeguarding adults and the training undertaken by staff has increased awareness of safeguarding adult’s procedures and reduced the risk of abuse occurring. EVIDENCE: There is a complaints policy and procedure in place at the home and the complaints procedure is displayed in the entrance. There is a complaints form available should anyone wish to make a complaint but there is no complaint log to enable formal complaints to be recorded and monitored. The manager informed the inspector that she intends to introduce a ‘grumbles’ book; there is already a comments book in place. This includes compliments about the staff and about the food provided, and a comment about the difficulties of wheelchair access. The relative that returned a survey recorded that they did not know how to make a complaint; the manager should ensure that everyone is aware of how to make a complaint. The manager informed the inspector that three staff have now completed safeguarding adults training. The manager has not yet attended training specifically designed for managers; care staff and the manager should attend Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 16 the training that is specifically designed for them 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. There are appropriate policies and procedures in place that have been produced by the home, and the Hull and East Riding policy is also in use. The staff handbook includes information on safeguarding adults and staff receive this prior to commencing work at the home. Staff sign a document to record that they have read the policies and procedures in place at the home, including safeguarding adults and whistle blowing. In surveys returned to the CSCI, staff demonstrated a good understanding of the policies and procedures on both safeguarding adults and whistle blowing. Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 17 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 this 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 well maintained and does not include all of the furniture and fittings that are needed to accommodate the number of service users that it is registered to accommodate. Hygiene is compromised by the lack of hand washing facilities in the laundry room and by the lack of domestic staff. EVIDENCE: There is no maintenance programme in place but there is a maintenance book in use; staff record any repairs that need to be done and the maintenance person undertakes these repairs and records when the work has been completed. Radiator covers have been fitted in bedrooms and in communal areas of the home but these have not yet been painted. There is a temporary door dividing the kitchen from a communal corridor and this needs to be made into a safe, permanent door to ensure the safety of service users. The Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 18 bathroom has recently been refurbished and is almost ready to be used by service users; this room includes enough space to accommodate service users that require the use of mobility equipment and/or assistance from staff. The main living room is decorated in a homely and comfortable fashion with good quality furnishings and fittings. On the day of the site visit there was a mobility scooter, a shower chair and the medication trolley stored in the small living room; alternative storage space should be identified for these items so that there is an area available for service users to sit quietly or to meet with family and friends. The dining room is pleasantly furnished. The inspector noted that the home does not have enough chairs and dining room furniture to accommodate the number of service users that the home is registered to accommodate. The garden is enclosed but needs to be made pleasant for service users to sit out and enjoy the fresh air. One social care professional recorded in a survey, ‘The home has had money spent on it but it doesn’t seem to be moving forward’. A bedroom was being refurbished on the day of the site visit. This was due to be occupied by a service user that uses a wheelchair in 3 days time. The room still needed to be decorated and furnished but the manager was confident that it would be ready for occupancy by the weekend. The room had been fitted with a ramp to replace a steep step; the manager was advised to take advice about the gradient of the slope, as the inspector considered it to be too steep and therefore unsafe. Some bedrooms are in the process of being refurbished but those shown to the inspector as rooms to be used for respite service users did not include all of the furniture that needs to be provided. For example, a television was placed on a footstool and one of the rooms did not have a wardrobe. New furniture had been purchased for other empty rooms and the inspector recommends that this be used to furnish the respite rooms and other rooms that had furniture missing or had furniture that was in a poor state of repair. Some carpets in bedrooms are very worn and need to be replaced; others need to be cleaned. The equipment provided in the laundry room is satisfactory but facilities need to be provided so that staff can either wash or disinfect their hands. There were no offensive odours on the day of the site visit and ground floor communal areas of the home were clean. However, private accommodation and the first and second floors of the home was untidy and carpets had not been vacuumed. There are currently no domestic staff employed at the home and the cook is on sick leave, so care staff have to carry out domestic duties and catering duties as well as care duties. Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 19 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 poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home does not currently employ enough staff to fulfil the care needs of service users. The recruitment and selection of staff is not robust and this leaves service users in a vulnerable position. Staff have attained qualifications and undertaken training programmes, but there is no evidence that thorough induction training takes place. EVIDENCE: There is a staff rota in place that records that there are 2 or 3 care staff on duty throughout the day and two staff on duty during the night. However, on the day of the site visit there was the manager, a care worker and another care worker acting as cook on duty. The manager informed the inspector that there is now herself, five care staff and a cook employed at the home, although the cook is currently on sick leave. Records evidence that agency staff are used rarely and that the home are relying on support from other homes in the group to maintain staffing levels. The manager informed the inspector that they are in the process of recruiting staff. The role of each member of staff is not recorded on the staff rota; this is important as some staff take on more than one role and the staff rota should record the specific role each person is taking on each day. The four staff that returned a survey stated that there are not enough staff on duty to meet the Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 20 residents’ needs. The inspector advised the manager that current staffing levels were not sufficient to allow for any new admissions. Over 50 of care staff at the home have achieved NVQ Level 2 in Care. There is a training and development matrix in place at the home but it is out of date, i.e. it includes staff that no longer work at the home and does not include a record of recent training undertaken. Two staff are currently undertaking training on infection control and some care staff are due to undertake fire safety training on the 23rd July. The manager informed the inspector that all staff have recently undertaken moving and handling training; this was confirmed in records seen by the inspector. There are no clear records to indicate that new staff have undertaken induction training; there should be evidence that staff have had the training needed to enable them to meet the assessed needs of service users. The inspector examined the recruitment records for two care staff. These included an application form; one had not been signed by the applicant and another did not include details of a second referee. Some references were addressed ‘to whom it may concern’ and this could result in unsafe people being employed by the home; references should be requested by the manager and returned to the manager to ensure their authenticity. There was a record of a Protection of Vulnerable Adults (POVA) first check for both employees but no record of a subsequent CRB check for one of them. One of these applicants had had a telephone interview and this is not acceptable practice; the interviewer should meet the applicant in person so that they are able to confirm their identification records. New staff had been given a contract of employment but these were contracts for home carers rather than care workers. There was information available in the home about a domiciliary care agency operated by the organisation from their headquarters in Bradford. The registered provider has been made aware that, should they wish to operate a domiciliary care agency in the Bridlington area, they would need to register a branch office with the CSCI. Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 21 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. There is no registered manager at the home. Quality monitoring systems do not allow service users to affect the way in which the service is operated. The health, welfare and safety of service users is not protected and the financial interests of service users are not safeguarded. EVIDENCE: The manager is due to have an interview this week to become registered with the Commission for Social Care Inspection. The manager informed the inspector that she has almost completed the Registered Manager’s Award, but that she is currently having difficulty accessing a training company to enable her to finish the award. The manager informed the inspector that she Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 22 undertakes in-house training with the rest of the staff group to ensure that her practice is kept up to date, and that she also accesses the CSCI website. One social care professional recorded in a survey, ‘Staff morale needs to be improved – the manager needs to be more visible, open door etc.’. This comment was discussed with the manager on the day of the site visit; the manager explained that this may be because she has had to work a lot of care shifts to cover staff absences and has struggled to keep up with administrative work. There is a basic quality assurance system in place but it is not yet fully operational. Audits have taken place on staffing levels, décor and menus but no surveys have yet been carried out with service users to enable them to influence the way in which the service is operated. A survey has been sent to relatives; some comments were dealt with on a one to one basis by the manager, but the overall outcome was not collated or published. Staff meetings and service user meetings take place. There is no annual development plan in place and the pre-inspection questionnaire completed by the manager records that no policies and procedures have been reviewed since 2005. Some personal allowances are held for service users. Records include a column for monies paid to the home, monies paid out and the balance remaining, but balances are not recorded for every transaction made. The records and actual monies held were examined by the inspector on the day of the site visit, and they did not balance. The inspector recommends that the balance is recorded following all transactions, and that balances held are checked on a regular basis by the manager and another member of staff to ensure that monies held are accurate, and to protect staff from accusations of neglect. There is a written statement of the policy, organisation and arrangements for maintaining safe working practices, including appropriate risk assessments. The landlord’s gas safety certificate expired on the 12th June 2006 and there was no current annual fire test certificate in place. Both systems have been serviced since the day of the site visit and copies of certificates have been sent to the CSCI. There is still no certificate in place to confirm that the electrical installations within the home are safe. On the day of the site visit the outbuilding used to store cleaning materials was not locked; this could put service users at risk. The passenger lift was serviced in June 2007 but bath hoists at the home have not been serviced since November 2005. The home has its own equipment to enable the handyman to check the safety of portable appliances, and this has been calibrated as required. Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 23 The handyman is responsible for testing room temperatures, water temperatures at outlets accessible to service users, the nurse call system and the fire alarm system. None of these had been tested since May 2007 – the handyman brought all of these tests up to date on the day of the site visit. The manager must ensure that in-house tests of equipment take place at the intervals recorded in the fire risk assessment and other guidance. Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 24 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 2 8 2 9 1 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 3 17 X 18 3 2 1 X 2 X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 1 X X 1 Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement The medication trolley must be relocated to ensure that medication is stored at the correct temperature and in a safe place, and does not inconvenience service users. All staff that administer medication must have undertaken accredited training, and there must be a sample of their signature available to enable records to be checked. The door between the kitchen and the corridor must be made safe. Communal areas of the home should include enough space and sufficient furniture to enable the number of service users that the home is registered to accommodate to live there in comfort and safety. The ramp within a bedroom should be checked to ensure that it is safe for use. All staff must have a CRB check prior to working unsupervised in the home. Previous timescale of 1/09/06 not met. DS0000062588.V345108.R01.S.doc Timescale for action 31/10/07 2. OP9 13(2) 18(1)(a) 31/10/07 3. 4. OP19 OP20 23 23 31/10/07 31/10/07 5. 6. OP22 OP29 23 18/19 30/09/07 04/07/07 Birchdale Version 5.2 Page 26 7. OP29 18/19 8. OP30 19 9. OP33 16/24 10. 11. OP35 OP38 16(2)(l) 12,13 12. OP38 12,13 13. OP38 12,13 14. OP38 12,13 Face to face interviews must take place when recruiting new staff. References must be requested by the manager and returned to the manager to ensure their authenticity. All staff must receive induction training to Skills for Care guidelines. Previous timescale of 1/10/06 not met. The quality assurance system must be developed to include feedback from all interested parties, the results of which must be published and inform future practice. Previous timescale of 1/11/06 not met. The manager must ensure that monies held on behalf of service users balance with records held. An electrical wiring safety certificate must be available for examination at the home. Previous timescales not met. Equipment at the home, including the fire alarm system and gas appliances, must be serviced at required intervals to ensure the safety of service users and staff. In-house health and safety checks must take place at the intervals that have been decided by the home to ensure the safety of service users and staff, i.e. water temperature tests and tests of the fire alarm system. Cleaning materials must be stored in a locked cupboard at all times. 04/07/07 04/07/07 31/10/07 04/07/07 31/10/07 04/07/07 04/07/07 04/07/07 Birchdale DS0000062588.V345108.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. Refer to Standard OP7 OP7 Good Practice Recommendations Service users should be involved in the care planning process. Care plans should include a photograph of the service users to assist new staff with identification and to assist the emergency services should a service user be missing from the home. Nutritional screening is not currently effective – it must be consistent to be effective. The registered person should consider purchasing a separate fridge to store medication. Medication administration records should be checked periodically to ensure that recording is satisfactory. Service users 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 service users and others. A menu should be displayed to encourage independence and to promote conversation. There should be a complaints log in place, and all stakeholders should be made aware of how to make a complaint. Staff and the registered manager should 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. The garden should be made pleasant for service users to sit out. Some carpets need to be replaced and others need to be cleaned. Equipment should not be stored in communal areas of the home. Bedrooms should include all of the furniture and fittings to make the room safe and habitable. The home should be kept clean at all times. The role of each member of staff should be recorded on the DS0000062588.V345108.R01.S.doc Version 5.2 Page 28 3. 4. 5. 6. 7. 8. 9. 10. OP8 OP9 OP9 OP12 OP14 OP15 OP16 OP18 11. 12. 13. 14. 15. 16. Birchdale OP19 OP19 OP20 OP24 OP26 OP27 17. 18. 19. OP29 OP31 OP31 staff rota. The manager should ensure that application forms have been completed correctly by applicants. The manager should be registered with the CSCI. There should be an action plan in place that records details of how the manager will achieve the required qualifications within 2 years of the date of appointment to the post. Birchdale DS0000062588.V345108.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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