Inspection on 09/06/08 for Birchdale Nursing & Residential Home

This inspection was carried out on 9th June 2008.

CSCI found this care home to be providing an Adequate 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 Nursing & Residential... 13/06/07

Birchdale Nursing & Residential... 31/01/07

Birchdale Nursing & Residential... 01/06/06

Birchdale Nursing & Residential... 21/10/05

Birchdale Nursing & Residential... 19/04/05

Birchdale Nursing & Residential... 05/11/04

Birchdale Nursing & Residential... 29/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Birchdale Nursing & Residential Home Moore Street Gateshead Tyne & Wear NE8 3PN Lead Inspector Irene Bowater Unannounced Inspection 9th June 2008 08:30a 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 Nursing & Residential Home DS0000018168.V366863.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 Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchdale Nursing & Residential Home Address Moore Street Gateshead Tyne & Wear NE8 3PN 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) 0191 477 6777 0191 477 4241 None Four Seasons Healthcare (England) Limited (Wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Marion Taylor Care Home 63 Category(ies) of Dementia (28), Mental disorder, excluding registration, with number learning disability or dementia (15), Old age, of places not falling within any other category (10) Birchdale Nursing & Residential Home DS0000018168.V366863.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 with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 10 Dementia - Code DE, maximum number of places 28 Mental Disorder, excluding learning disability or dementia, Code MD maximum number of places 15 The maximum number of service users who can be accommodated is: 63 13th June 2007 2. Date of last inspection Brief Description of the Service: Birchdale Residential and Nursing home is a 63-place purpose built facility. All of the bedrooms are single rooms. The home predominantly provides a service for older people with a dementia type illness. The home has three floors of accommodation. The home has recently had a major refurbishment and there are now four separate units. The top floor unit is called the Gables and has seven rooms in use. The other rooms are being refurbished. This is presently an all male unit. The middle floor has two units. The Oaklands is a ten-bedded unit, which provides general nursing care and the Woodland is a seventeen bedded unit, which provides social and personal care for people with Dementia. Fernlea is the unit located on the lower ground floor and provides nursing care for people who have Dementia and Mental Health care needs. Each unit contains lounges, dining rooms, bathrooms, toilets and bedrooms. There is one main kitchen but each unit has a small kitchenette area where drinks and light snacks can be made. All areas are accessed via a central Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 5 reception area. There is a passenger lift that serves all 3 floors. The laundry is located on the lower ground floor and services the whole building. Birchdale has easy ramped access into the reception entrance on the middle floor. There is also good access around the homes corridors. The home is close to local bus routes and short walk from a metro station. The home is in a residential area on a steeply sloping street. There is good car parking at the front of the home. The weekly fee ranges between: Minimum £394 to £410 per week plus the free nursing care rate which is set Nationally . Rates for privately funded people vary from £410 to £430 per week. Other costs such as hairdressing (between £6-16), chiropody (£8.50) and toiletries are not included within the current fee level. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. Before the visit: We looked at: • Information we have received since the last visit on 13 June 2007. • How the service dealt with any complaints and concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • The views of people who use the service and their relatives, staff and other professionals The Visit: An unannounced visit was made on the 9 June 2008 and took one Inspector 9 hours to complete. During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors • Looked at information about the people who use the service and how well their needs are met • Looked at other records which must be kept • Looked at care planning documents for 6 people who use the service • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for • Looked around the building to make sure it was clean, safe and comfortable • Checked what improvements had been made since the last visit • We told the manager what we found. What the service does well: The staff collect information together about the person before anyone moves into the home to make sure they can meet their needs. Visitors are always welcomed and there are links with the local community. Staff are respectful and sensitive with people when helping them or when speaking to them. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 7 The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced and interesting diet. Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The registered manager makes sure that all checks and clearances are received before staff are employed. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. Comments from relative surveys included: “The service supports the residents and families to” “The home takes good care of X”. “For A the home is very suitable and we visited lots before we chose this one. The level of support is increasing” “The staff is caring and polite” What has improved since the last inspection? The Service User Guide and Statement of Purpose have been updated so that people can have enough information should they wish to live there. There has been a major variation of conditions of registration, which has been approved. In addition to providing care for people with Dementia and Mental Health Care needs there is now a separate ten bedded unit, which can provide general nursing care. The Company’s assessment tool is now completed in detail. Food and fluid charts are being completed in better detail. An activities person has been employed and any events are recorded. People’s health and personal care needs are being met. Staff have completed Safeguarding They now recognise signs of abuse and feel confident about identifying when to raise an ‘alert’ and protect those at risk. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 8 There has been redecoration and replacement of furniture, which has vastly improved the environment. There are now four units, which are to be staffed separately. Domestic staffing levels have been reviewed and there are now enough domestic hours to make sure the home is kept clean and free from any odour. The manager has been registered with the Commission for Social Care Inspection and suitable training courses are being sourced for all staff. 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 Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 9 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 Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 10 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): 1, 2 & 3. Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive clear information about the service and a comprehensive assessments of need before admission. This helps them make the right decision about using the service. EVIDENCE: There has been a major change to the registration of the home. The manager has updated the Service User Guide and Statement of Purpose to show how they will meet individual’s needs. There is an also clear detail about the qualifications and experience of staff, which was not previously available. Individual copies are available to potential and current people living in the home. And a copy is readily available in reception. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 11 Everyone is given a contract when they are admitted to the home. This sets out what people can expect to receive for the fees they pay and sets out terms and conditions of occupancy. Everyone admitted to the home has an assessment of all care needs, which is completed by care managers, nurse assessors and the home manager. The Company have an assessment document that included areas specifically about the needs of people who have a dementia or mental health related illness. Staff are also able to record what peoples assessed needs are and how they should meet these needs based on a “person centred approach to care”. The preadmission assessments are used as the basis of the care planning process for each person. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 12 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 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Access to health care is satisfactory, but lack of detailed care planning does not demonstrate that people’s needs are being fully met. EVIDENCE: Each person has a plan of care based on the admission information which was carried out by care managers, the home manager and where necessary nurse assessors. Staff complete pressure sore risk, dependency, moving and handling, nutritional assessments using the Malnutrition Universal Screening Tool (MUST), continence and fall risk assessments. These tools help the staff understand the level of risk each person and helps them complete a care plan. The care plans again differed in style and content. One care plan showed in detail how that person’s needs were met. It was clear and detailed about previous lifestyle, likes and dislikes, health and social care. For example, this Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 13 person’s favourite colour is blue, enjoys the church service and going out with family. There is also information about activities and how staff helps this person keep a degree of independence. Another care plan gave clear information about how to use the hoist and monitoring falls and any weight gain or loss. However, the risk assessments for dependency and nutrition had not been updated since November 2007 and a care plan for social care was written in December 2007 but had not been evaluated. Other care plans had been written in April 2008, none of these had been updated. The four care plans looked at on the nursing unit found that initial care plans and risk assessments had been completed. One showed that risk assessments had not been updated from October 2007 to March 2008.A care plan written in August 2007 about how one persons “best interests” would be looked after had not been updated until April 2008. Other parts of the care plan have gaps from October 2007 until May 2008. The other care plans showed the same problems. They had not been updated and did not reflect the current health care needs of individuals. One showed that a person was at very high risk of pressure damage but this had not been updated from February 2008 to June 2008. One persons daily progress notes records that they could be aggressive and may need three people to help them but there was no care plan to show what staff should do to support this person. Four care plans showed that social care assessments were not detailed and social care plans are not completed. This means that people’s likes, dislikes and previous lifestyles are not always taken into account when planning care. Staff still need to develop care plans on the nursing unit to show how peoples previous history and lifestyle affects their current needs and aspirations. Decisions on how care is given are based on health care needs and not on a person centred approach. Daily progress records and food and fluid charts are being completed in more detail about daily personal care. However there are still some unclear records. For example, “settled day” and “assistance give by two” do not show how staff are giving support and sometimes-complex nursing care to people. Everyone has access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s and other health professionals including, dentists, opticians and chiropody services. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 14 Appropriate pressure relieving devices are available. Several people have air cell mattresses and cushions to prevent pressure damage. Advice is sought from, occupational therapists, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. Medication policies and procedures are available for staff to use. The nursing staff are responsible for the safe administration of medicines to those who have nursing needs. The senior care staff administer medication to people who have social and personal care needs. The non-nursing staff have completed a “Safe Handling of Medicines” course. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. When staff are handwriting directions on the M.A.R. sheets there are not two witness signatures. This would show that the correct directions had been carried out and would reduce the possibility of error. The treatment room on the Fernlea Unit is very small and cramped. On the day of the visit this room was untidy cluttered and very warm. The temperature of this room is not recorded daily to make sure 25C is not exceeded. Many of the staff have worked in the home for some time and know the people they care for well. All of the care staff worked very hard to make sure everyone was treated with respect and their rights to privacy and dignity maintained. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 15 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 & 15. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Opportunities to take part in meaningful activities and keep control of everyday decisions are limited, and mealtimes are not always well organised. This prevents people from leading full and active lives. EVIDENCE: The home now has an activities person who is employed for thirty hours a week. Since the last visit there has been an improvement in how people are supported to spend their social and leisure time. There are pictures of events including arts and crafts and parties. People have enjoyed playing dominoes, skittles and floor snakes and ladders. There is a also a monthly quiz and newsletter and people have enjoyed a Pie and Supper and a Cheese and Wine Evening. There is again input from a charitable organisation called Equal Arts who involve residents in artwork and some of the artwork is on display on the walls. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 16 Clear records are now available about how people spend their time and further work is being developed using information from the Bradford University Dementia Care Site. Staff haven’t fully developed care plans to show how peoples previous history and lifestyle affects their current needs and aspirations. The staff on the two upper units had plenty of time to make sure individual needs were being met. Some were listening to music, chatting and knitting. Due to the dependency of the people living on the nursing unit staff had little time to provide any social care. Their time was spent making sure that individual personal care needs were being met. Given the dependency of the people and the staffing levels of one nurse and two carers, it is difficult to make sure that individual social care needs are consistently met on a daily basis. Information about advocacy is available in reception and on notice boards. Some people have access to solicitors and the Court of Protection to make sure they can have some control over their lives. Many people have brought small items with them making their rooms homely and reflective of their previous lifestyles, religious beliefs or cultural backgrounds. The cook is very knowledgeable about making sure everyone receives nutritious and well-balanced meals. Menus are being reviewed in line with the guidance “Food for Thought”. And, the manager is also starting to provide the menus in picture styles so that people can make proper choices about what they would like to eat. There are small kitchens on each unit .The cook regularly checks that there are plenty supplies of milk, juices, sandwich fillers, bread, fruit, yogurts, biscuits available to make sure people receive a nutritious and fortified diet. Again there was a difference in the mealtime experience. Tables were nicely set on the upper two units with tablecloths, cutlery and crockery. Some people were able to self-serve drinks with milk sugar and pots of tea on the tables. Staff were constantly asking if they wanted more hot and cold drinks and they sat with people supporting them whenever necessary. Comments included “I have plenty to eat” and “my food is always nice”. On the nursing unit cloths covered tables but they were not set. Some knives and forks were put out just before the meal was served others were given a spoon to eat their meal with. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 17 When asked why the tables were not set ready for a meal the answer was “they will only put everything on the floor so tables are not set for meals”. The two care staff worked extremely hard to try to make sure they supported people with their meal. However, there were only two of them to assist ten people which meant lunch took over an hour and half and it was difficult for staff to make sure everyone had sufficient hot food at this time. All meals are prepared in the main kitchen and sent to each unit plated in a hot trolley. Choices on the day were mince, mashed potatoes, carrots, cabbage and swede. And the alterative was chicken nuggets, chips and beans. Choices for dessert were bread and butter pudding with custard, yoghurts and milk. Soft and liquidised food was presented attractively to encourage people to eat. There were plenty of snack foods and drinks available throughout the day. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 18 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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good complaints and protection procedures are in place and effectively followed to ensure that people and their relatives are listened to and protected from abuse. EVIDENCE: The Company has a comprehensive complaints procedure, which is displayed in all areas of the home. It is also available in the Service User Guide, which is available in reception. There is a complaints book which shows that all complaints and concerns are taken seriously and there is written evidence of investigations and outcomes. There have been no complaints since the last visit. The Company have clear Safeguarding policies and procedures. Training is initially completed during induction and then through workbooks. The manager has completed a two-day “Alerter” training course which links into the Local Authority framework. Staff were very clear about what they would do should they have any suspicions or receive any allegation of abuse. There have been no safeguarding alerts since the last visit Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 19 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, 21, 22, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and a pleasant, clean and comfortable place for people to live. EVIDENCE: During the last year the home has completed major refurbishment programme and has changed the units within the home. The top floor is called the “Gables” This only has seven rooms in use as the others are being refurbished. This is currently a male only unit. The middle floor has two separate units. One is a new ten-bedded unit called Oak lands’ and it provides general nursing care for both men and women. The Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 20 Woodlands is a seventeen-bedded unit, which provides personal and social care for men and women who have dementia care needs. The unit on the lower floor is called “Fernlea” and provides nursing care for men and women who have a dementia and a mental health illness. This unit has access to a conservatory and garden, which is being landscaped. There is also a “sensory” room, which is being repaired and will soon be ready to use. All of the units have lounges and dining rooms, which have been refitted and redecorated to a good standard. People are unable to access the garden area independently, mainly due to their state of health but also because doors are kept locked on the upper units. Bathrooms and toilets have been repaired and refurbished and there are appropriate aids and adaptations available. The problems with the constant dripping taps in bedrooms, bathrooms and toilets have been put right. All of the bedrooms are for single occupancy. People have brought small items with them making their rooms homely and reflective of their lifestyles. But the quality and condition of furniture varies, for example, some of the bedroom furniture is worn and shabby. Other bedrooms have been refitted with good quality furniture including profiling nursing beds. The main focus was to refurbish the home, which has nearly been done. This has meant that there is little signage throughout the home that would help people find their way around. The manager is starting to “theme” each area so that people will be able to find their own way around the home. For example, musical, sport, domestic and kitchen life pictures, equipment and posters of past events. The laundry is separate and is kept locked. The sink unit has been replaced and the area was generally clean and tidy. On the day of the visit the home was clean, tidy and fresh smelling. A sluice disinfector has been provided on the new unit but the disinfector on the Fernlea Unit does not work. Birchdale Nursing & Residential Home DS0000018168.V366863.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 & 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Systems around recruitment, selection and training of staff are satisfactory but the staffing levels are not always sufficient to address the full range of needs of people living in the home. This means that people’s lifestyles are restricted and overall affects their quality of life. EVIDENCE: There have been a lot of changes in staffing since the last visit to the home. The home has managed to employ registered mental health and general health nurses. Each unit is staffed separately. The Gables has one carer over twenty-four hours. The Woodlands has two care staff and one senior carer during the day and overnight there are two staff. The Oaklands is not staffed, as it is empty. The Fernlea Unit has one qualified nurse over twenty four hours with two care staff from eight am to eight pm and one carer overnight. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 22 Dependency levels on the nursing unit means that ten of them need two staff to assist with all of their daily living needs. Three staff during peak times is not sufficient to make sure that all of their needs are met on an individual basis. This is especially so when the nurse is called away at mealtimes or is busy with other things. An activities person has been employed and there is now domestic cover seven days a week. Staff are continuing with NVQ level 2 training to make sure the 50 target is reached. The records for recruitment were satisfactory. There was evidence of Criminal Record Bureau checks, Protection of Vulnerable Adult checks, two written references, proof of identity and professional identity numbers for registered nurses. New staff have an induction period, which is over twelve weeks and follows the “Common Induction Standards” from Skills for Care. They are given a “Staff Handbook” which covers all aspects of employment matters and care practice. It also covers equality and diversity and valuing that everyone has a contribution to bring to the home. There is training programme in place. All mandatory training is up to date. Other training includes, Mental Capacity Act, Infection Control, Assertiveness training, dealing with death and dying, bereavement and loss, End of Life Pathways, End of Life care for people with Dementia, subcutaneous fluids and customer care. Birchdale Nursing & Residential Home DS0000018168.V366863.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 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by a competent manager who makes sure that good quality assurance and safety systems are in place. This makes sure that people receive a good quality of care. EVIDENCE: The manager has been registered with the Commission. She has many years experience as a manager and holds the Registered Managers Award. She has completed a recognised training course in dementia care. She does not hold a nursing qualification. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 24 Audits of all care and other services are now being carried out with action and outcomes recorded. The regional manager visits on a monthly basis and completes a separate report. These reports are to make sure the quality of the home continually improves. The AQQA was completed and the information gave a reasonable picture of what was happening in the home. Further detail would show how they plan to improve over the next year. Staff and relatives meeting are now taking place with minutes kept. There are individual statements of accounts and transactions that are held on computer. They are able to obtain a print out at any time during office hours. Monies are generally held in one non-interest account although some people have had their money put into an interesting barring account. Entries were clear with signatures available. A full audit of personal allowances has being undertaken. Accidents are clearly recorded and the manager completes monthly accident analysis to examine and track any trends. Regular maintenance checks are carried out both internally and from external contractors. Several of the internal maintenance checks were not up to date. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 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 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15(1) Requirement The registered persons must ensure that the care plans are reviewed at least monthly, are person centred and reflect up to date practice This must include how to deal with behaviours that challenge. Timescale of 31/08/07 not met The registered persons must ensure that all hand written directions on the medicine administration records have two witness signatures. Timescale of 31/08/07 not met The registered persons must ensure the treatment room on the Fernlea Unit is kept clean and the temperature monitored so that 25 C is not exceeded The registered persons must ensure that people are supported to make choices regarding their everyday lives and this must be recorded in detail The registered persons must review the organisation of the mealtimes on the Fernlea Unit DS0000018168.V366863.R01.S.doc Timescale for action 01/09/08 2 OP9 12,13 01/08/08 3 OP9 12,13 01/08/08 4 OP14 12 01/08/08 5 OP15 12,16 01/08/08 Birchdale Nursing & Residential Home Version 5.2 Page 27 6 7 OP26 OP27 13 18,24 8 OP30 13,18 9 OP38 12,13,23 The registered persons must repair or replace the sluice disinfector on the Fernlea Unit The registered persons must ensure that there are sufficient staff at peak times on the Fernlea Unit An appropriate training course in dementia care must be sourced for senior staff. Timescale of 01/09/07 not met The registered person must ensure that all maintenance checks are carried out with records kept. Timescale of 30/10/07 not met. 01/10/08 01/09/08 01/09/08 01/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard OP7 OP20 OP28 Good Practice Recommendations It is highly recommended that plain English be used in care planning documentation. The registered persons should continue to change colour schemes and provide pictures and signage to help people with memory loss find their own way around the unit. It is highly recommended that the current NVQ training continue to ensure that a minimum of 50 of care staff achieve NVQ Level 2 Award. Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Birchdale Nursing & Residential Home DS0000018168.V366863.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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