Inspection on 01/11/06 for Birchlands

This inspection was carried out on 1st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Birchlands 18/02/09

Birchlands 11/05/06

Birchlands 17/10/05

Birchlands 21/04/05

Birchlands 26/11/04

Birchlands 11/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Birchlands Birchlands Barley Mow Road Englefield Green Surrey TW20 0NP Lead Inspector Sandra Holland Key Unannounced Inspection 1st November 2006 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 Birchlands DS0000013569.V316605.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. Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchlands Address Birchlands Barley Mow Road Englefield Green Surrey TW20 0NP 01784 435153 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) www.anchor.org.uk Anchor Trust To Be Confirmed Care Home 51 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (51), of places Physical disability over 65 years of age (12) Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2006 Brief Description of the Service: Birchlands is a residential care home in a substantial detached property that has been purpose built to provide accommodation for fifty one service users. The home is owned by the Anchor Trust Group and is located in Englefield Green, near Egham. A selection of facilities and services including shops, church, public transport and G.P. surgeries are available locally. The home is a two storey building served by a passenger lift to both floors. A wheelchair lift provides access from the first floor to one of the seven residential units which the home is divided into. Each unit accommodates between 6 and 8 service users and has its own communal lounge and dining room with a kitchenette. Units on the ground floor have access to the garden via french doors from the lounge. All bedrooms are for single occupancy and have wash basins. Toilets and bathrooms, most with easy access baths or with a hoist facility, are provided on each of the units. The home has recently undergone a major renovation and refurbishment to improve facilities for residents and staff, and particularly for those residents with dementia. There is a large communal lounge, equipped with a television, music centre, piano and selection of books. This room is used for activities and has access to an enclosed garden area. A further area with comfortable seating and a music centre is situated centrally on the first floor. The fees at Birchlands range from £438.73 to £697.00 per week. Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was the second to be carried out in the Commission for Social Care Inspection (CSCI) year April 2006 to June 2007 and was carried out under the CSCI “Inspecting for Better Lives” programme. This key inspection was carried out to reassess standards assessed as adequate or poor at the previous inspection carried out on 11th May 2006. Mrs Sandra Holland, Lead Inspector carried out the inspection over seven hours. Ms Lucy Ncube, Deputy Manager was present representing the service and Mr Sam Ndlovu, Manager arrived later. As the deputy manager had a prior engagement, Ms Carole Shepherd, Team Leader escorted the inspector on a tour of the premises and was able to provide much of the initial information. Areas of the premises were seen and a number of records and documents were sampled including residents’ individual plans, residents’ monies records, medication administration records and staff files. A number of residents, staff and two visitors were spoken with. A selection of CSCI feedback cards were supplied for distribution to residents, visitors and healthcare professionals in order to gather the independent views of those involved in the support of residents. Twelve of these were completed and returned by residents, eight were returned by relatives or visitors and one from a healthcare professional. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. The inspector would like to thank the residents, staff and management for their assistance with the inspection process and for their hospitality. What the service does well: A number of residents indicated that staff are available to support them when needed, that staff listen to them and act on what residents say. Some residents stated that the staff are kind and offer them choices in their care. A resident stated that staff assist her with all activities of daily living, and do so in a manner that respects her dignity and privacy. Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 6 Many residents gave positive feedback regarding the food provided by the home, stating that meals were varied, tasty and generally met their expectations. If residents prefer to have their meals in their rooms, this choice is accommodated. The majority of residents who responded on the CSCI feedback forms, stated that they knew who to speak to if they were unhappy. The home was very clean, bright and freshly aired and presented as a comfortable place to live. The staff and management are to be commended for maintaining overall improvements in the standard of the service provided, during the extended period of upheaval and renovation. What has improved since the last inspection? What they could do better: Although the overall standard of information in residents’ individual plans has improved, some areas of the plans have not been completed, signed or dated and there were also some inconsistencies in the record keeping in the plans. Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 7 Some of the known risks to some residents had not been assessed. The complaints policy supplied by Anchor Homes needs to be reviewed and revised to suit the needs of the residents. 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. Birchlands DS0000013569.V316605.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 Birchlands DS0000013569.V316605.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): 1, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are assessed before they are admitted to the home. EVIDENCE: Copies of the home’s statement of purpose and service user’s guide are held on file by CSCI, but these are outdated. It was agreed that updated copies of these would be forwarded to CSCI. The individual plans of a number of recently admitted residents were seen and it was clear that an assessment of the residents’ needs had been carried out before they were admitted. Staff advised that where possible, residents come to the home for an assessment day. This enables the prospective resident to view the home and meet other residents and staff, whilst enabling staff to fully assess the needs of the resident. Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 10 The deputy manager advised that a number of residents are supported financially by a local authority and where this is the case, the needs of prospective residents have also been assessed under the care management process. Where this is applies, a copy of the care management assessment has been obtained and retained in the home. The manager advised that intermediate care is not provided at the home. Birchlands DS0000013569.V316605.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of information in residents’ individual plans has improved, but further information is required. Assessments of any known or identified risks to residents must be carried out. Medication appears to be appropriately managed. Residents are supported with dignity and their privacy is respected. EVIDENCE: As stated previously, the care plans of a number of recently admitted residents were sampled. The plans are used to guide staff to the support and care needs of residents, and those seen contained detailed information in a more accessible way. The manager stated that the home is in the process of introducing a new style of individual plan supplied by Anchor Homes, and this is currently being used for all newly admitted residents. It is hoped that the new style plans will more effectively guide staff to the needs of residents and it is planned to gradually phase these in for all existing residents. Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 12 It was noted that for some residents, not all areas of the plan had been completed and there were inconsistencies in the recording of some of the information. The deputy manager stated that she has been monitoring the use of the new style individual plans, and has been supporting staff to ensure they are completed correctly and contain the appropriate information. Indicators had been placed in the individual plans to alert staff to areas of any shortfall. The manager advised that a series of training sessions are being carried out, with the support of the Anchor national care team, to ensure staff use the plans effectively. The manager had also drawn up an action plan to ensure that senior staff received training first, to enable them to support care staff. It was noted that assessments of some of the known risks to residents had not been carried out. For one resident who has a history of falls, and for another who uses an electrically operated chair, no assessments had been carried out. These must be carried out to establish the level of any risk and what can be done to minimise or eliminate it. Medication records were seen and no gaps were noted on the Medication Administration Record (MAR) charts. The home has implemented a system for checking that medication has been correctly administered and if any gaps are noted in the records, senior staff address this promptly with the staff member involved and record any action taken. To support new staff members who have not completed their medication administration training, senior staff administer medication on the units to which new staff are allocated. Two senior staff were observed carrying out a medication audit, to ensure that medication had been administered appropriately and that sufficient stock was held. The amount of medication held was checked with the record held and these accurately matched. Residents were seen to be treated with dignity and spoken to in a respectful manner. Personal support and care was given discreetly and with residents’ privacy maintained. Residents stated that staff are polite and kind, respect their privacy and that they are treated with dignity at all times. Two requirements have been made regarding Standard 7. Birchlands DS0000013569.V316605.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A new activities coordinator is being recruited. The home assists residents to maintain contact with relatives and friends and residents are encouraged to make choices. A well-balanced and varied menu is offered. EVIDENCE: The home has employed two activities organisers this year who have both subsequently left for personal reasons, and a new activities coordinator is in the process of being recruited, the deputy manager advised. During the period without an activities coordinator, care staff have been allocated to arrange activities for residents. An activities programme showed that a variety of activities were planned for each week day morning and afternoon. On the day of inspection, residents were enjoying a game of carpet bowls in the main lounge/dining room, supported by a volunteer who has assisted at the home for many years. It was pleasing to see digital photographs displayed in the lounge, of the Halloween party that residents had enjoyed the previous evening. The photographs had been produced very speedily and these would enable and support residents to recall the event. Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 14 The majority of residents were in the lounge/dining room on the day of inspection, as new carpets were being fitted on one unit and rooms were being reinstated following the refurbishment of another unit. Some residents remained in the lounge areas on their units and a number of residents who were in their rooms, stated they were there from personal choice. The majority of residents indicated on their feedback cards that there is usually an activity arranged that they can take part in, whilst two visitors indicated that there should be more activities to stimulate residents. A number of visitors were seen entering the home during the day and many residents talked about visits from their families and friends. The home holds a church service regularly on one of the units and some residents stated that they attend this or go to an outside church. All of the comments made in regard to the food provided were positive, and residents stated that they liked the choices, the variety of the menu and the quality and quantity of food. One resident stated that they prefer to eat their meals in their bedroom and this choice is accommodated. Birchlands DS0000013569.V316605.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel confident that they complaints will be taken seriously and complaints are managed appropriately. Staff are aware of their responsibilities in the protection of residents. EVIDENCE: A complaints policy and procedure is available in the home and is supplied to residents in their service user’s guide, the manager stated. The manager advised that the complaints policy on display is the Anchor organisation’s corporate policy, which has recently been reissued to incorporate the organisation’s logo. It was required at previous inspections that the corporate complaints policy was reviewed and revised, but it was noted that the content of the policy had not been changed. It is required that the policy is reviewed and revised to meet the needs of the residents who are all elderly and frail, and many of whom are physically disabled or have dementia. The current policy emphasises the need to write to the organisation with complaints which would not be easy for the resident group to do. From speaking to residents and from their feedback card responses, it was clear that they felt able to approach staff or the manager with any complaints or concerns. It was pleasing that residents commented on their feedback Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 16 cards that they could speak out, stating that they would speak to a carer or management if they were not happy and could voice their opinions when needed. The manager and deputy manager were both observed to interact with residents in an informal and friendly manner, whilst maintaining respect and dignity. The manager advised of a complaint that had been made since the last inspection, and of the actions taken in response and it was clear that the complaint had been managed appropriately. Letters in response to complaints were seen and these referred to meetings which had also been held. Regular resident and relative meetings are held and provide another opportunity for residents to air their feelings about the home or to raise any issues, the manager advised, and minutes of recent residents’ meetings were seen. Staff spoken to stated that they would report any concerns they had about the abuse or potential abuse of residents, to the manager or the senior in charge, and would not hesitate to do so. A number of staff advised that they had received training in the safeguarding of adults and in the rights and responsibilities of residents. A requirement regarding Standard 16 has been made. Birchlands DS0000013569.V316605.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 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Major improvements have been carried out to ensure the premises are better adapted to meet the needs of all residents, and residents with dementia in particular. The home was very clean and tidy and appeared hygienic. EVIDENCE: The home has recently undergone a four month programme of major refurbishment and improvement, involving all areas of the home. This was carried out in order to create specially designed units for residents with dementia and as part of the home’s on-going planned improvement schedule. The manager advised that a specialist company had been engaged to consult with residents and staff about their preferences, and to advise regarding the decorative schemes that would assist all residents, but especially those with dementia. The company supplied a comprehensive report which provided Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 18 guidance and recommendations on the use of particular colours and the effects they have, such as soothing, restful or stimulating. The report also indicated how each of the individual units could be decorated and furnished to ensure they were personalised and could be more easily distinguished from each other. Colour coding has been used in the decorative scheme, to help residents find their way in the home and to aid their memory, the manager advised. The use of one paint colour that is not used anywhere else in the home, has been used on toilet and bathroom doors throughout the home and this is designed to enable residents to find those rooms more effectively. All areas of the home that were seen, were very clean, freshly-aired and wellordered. Hand-washing facilities with liquid soap and paper towels are provided in appropriate places. Staff were observed to use the personal protective equipment that is supplied to prevent the spread of infection, including aprons and gloves. The laundry is situated away from food preparation and serving areas, is equipped with the required machines and is staffed by allocated staff, the team leader advised. Birchlands DS0000013569.V316605.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A team of staff are employed to meet the needs of residents. The required recruitment information and documents have been obtained and staff receive induction and training according to their role. EVIDENCE: From speaking to staff and reviewing the staff rota, it was clear that a full team of staff are employed to meet the needs of residents. A team of care support staff work alongside housekeeping staff, kitchen staff, a handy person, a laundry person, a receptionist, an administrator and an activities coordinator. A management team of senior care staff work under the leadership of the recently appointed manager and deputy. A number of staff have undertaken National Vocational Qualifications (NVQ’s) in care, to level 2 or above. From information previously supplied, approximately thirty percent of staff have achieved this qualification. The manager advised that a number of senior staff are currently training as NVQ assessors, to ensure sufficient assessors are available to support staff. The recruitment records of recently employed staff were seen and it was pleasing to see that the required records and documents had been obtained to safeguard residents. Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 20 Staff in the home advised that they have undertaken a number of training courses, some required by law, such as first aid, food hygiene and fire safety, and others to develop their knowledge and skills, such as NVQ’s and dementia care. The training undertaken by staff is related to the role they carry out. Housekeeping staff and the handyperson have received training in the Control of Substances Hazardous to Health (COSHH), as they are regular users of these products. A comprehensive induction training record is supplied by Anchor to each new member of staff the manager stated. This was seen to be in progress for one recently recruited member of staff and can be used by staff towards an NVQ or BTEC qualification. One member of staff was starting work at the home on the day of inspection and was reading through the home’s policies and procedures, to familiarise himself with them. The staff group is of mixed gender which reflects the resident group, although the cultural and racial diversity of the staff group is not reflected in the resident group. All of the residents who responded on the CSCI feedback cards indicated that they were British. Birchlands DS0000013569.V316605.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A new manager has been appointed, and he has submitted an application for registration with CSCI. The views of residents, their representatives and staff are sought, regarding the quality of the service offered. Residents’ monies held for safekeeping are appropriately managed and the health, safety and welfare of residents is promoted and protected. EVIDENCE: A new manager who was previously a trainee manager, has been appointed since the last inspection, and he has submitted an application for registration with CSCI. The manager stated that he has worked with Anchor homes for a number of years and has previously been a deputy manager and a project manager in other Anchor homes. The manager is ably supported by an Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 22 effective deputy manager and a team of senior care staff, who are now known as team leaders. The staff and management are to be congratulated for maintaining overall improvements in the standard of the service provided, during the recent, extended period of upheaval and renovation. It is clear that the management team are committed to obtaining the views of residents, their representatives and staff. A number of quality surveys have been supplied to these groups since the last inspection and the responses were sampled. The deputy manager advised that residents and their representatives are also invited to open meetings at the home, to discuss issues and exchange information, and minutes of these were seen. Regular visits to the home are also being carried out under Regulation 26. These visits are undertaken by a person nominated by the Anchor organisation, to monitor the quality of the service offered. During the visit, the person should speak to residents and staff, look around the premises and a short report of their findings should be written and left at the home. The records of recent visits were seen and these had been appropriately carried out. The administrator advised that monies are held for safekeeping for a number of residents and records are maintained of all transactions. The records are signed by two people and these are monitored on a weekly basis by the management team and are reconciled each month. The amounts held were checked with the records held and the amount present was over by a few pence. A computer balance sheet is also maintained but was not available on the day of inspection. This was forwarded to the inspector shortly after the inspection and the amounts were accurately reconciled. From information supplied, it is clear that the required maintenance and checks on systems and equipment in the home, are carried out appropriately, and to the required frequency, to promote the safety and welfare of all who live and work at there. During the tour of areas of the home, no hazards to the health or safety of residents were observed. A requirement regarding health and safety which was made at the last inspection carried out on 11th May 2006, has been met. This was that products hazardous to health must be stored in a locked cupboard. Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 23 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 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 24 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 Requirement The residents individual plan must be kept under review and kept up to date. Timescale unmet from 09/06/06. Unnecessary risks to the health or safety of residents must be identified and so far as possible, eliminated. The Anchor Home’s complaints procedure must be appropriate to the needs of residents. Timescale unmet from 18/11/05, 31/03/06 and 11/08/06. Timescale for action 29/11/06 2. OP7 13 01/11/06 3. OP16 22 02/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Birchlands DS0000013569.V316605.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!