Inspection on 11/05/06 for Birchlands

This inspection was carried out on 11th May 2006.

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

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

Other inspections for this house

Birchlands 18/02/09

Birchlands 01/11/06

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 Unannounced Inspection 11th May 2006 09:45 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.V288875.R01.S.doc Version 5.1 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.V288875.R01.S.doc Version 5.1 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) sharon.blackwell@anchor.org 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.V288875.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 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 serves 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. 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. Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the first to be carried out in the Commission for Social Care Inspection (CSCI) year, April 2006 to June 2007. As the inspection was unannounced, no-one at the home knew that it was to take place. Mrs Sandra Holland, Lead Inspector for the service and Mrs Meg McHugh, Regulation Inspector, carried out the inspection over eight hours. Mrs Maureen Burns, Manager, Mr Sam Ndlovu, Trainee Manager and Mrs Christine Conroy, Area Home Support Manager were all present representing the service. A number of records and documents were examined including individual plans of care, medication administration record (MAR) charts, staff files and activities programmes and all areas of the home were seen. Twenty four residents, fourteen members of staff, one healthcare professional and three visitors were spoken with. A pre-inspection questionnaire was completed by staff at the home and returned to CSCI. Some information referred to in the report was obtained from the questionnaire. An additional, unannounced inspection was carried out on 8th February 2006, to follow up a Position Statement provided by Anchor Homes. The position Statement was provided as an outcome of a meeting held with representatives of Anchor Homes. The meeting was arranged at the request of CSCI to discuss issues that had been raised by events in the home. A full report was not completed at that inspection, but the additional inspection response, which is not published, is available from CSCI on request. The people living at the home prefer to be known as residents and that is the term that will be used throughout the report. What the service does well: Some residents stated that the staff are kind and offer them choice for all things involving their care. A resident stated that staff assist her with all her activities of daily living and do so in a manner that provides her with dignity and privacy. There is an activities folder held on each unit which is a record of what the residents did during the day, if they took part in activities, had visitors, went out etcetera. This was seen as a useful tool. Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 6 Many residents gave positive feedback in regard for the food provided by the home, stating that meals were varied, tasty and generally met expectations. The home was clean, bright and freshly aired. What has improved since the last inspection? What they could do better: Although some of the plans of care sampled were kept up to date with monthly reviews, not all were. The Anchor Homes complaints procedure must be suited to the needs of the residents. It is recommended that further staff undertake National Vocational Qualifications in care to level 2, to ensure that 50 or more of the staff achieve this, in line with the National Minimum Standards (NMS). In the event that an applicant for employment at the home declares a health condition, it is good practice to request a medical reference or refer the applicant to an Occupational Health service. The manager must apply for registration with CSCI without delay. Monthly, unannounced visits to the home under Regulation 26 of The Care Home Regulations must take place and a record of these must be kept in the home. These visits must be undertaken by a person nominated by the Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 7 provider / parent 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 amounts of monies held for or on behalf of residents, must accurately match the record held. The home must be kept free from hazards to the health or safety of 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. Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 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.V288875.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments were in place. EVIDENCE: Those files sampled all contained a pre-admission assessment completed by the home or the care manager. It was however noted that on one of these assessments, it was recommended that a resident attend a day centre. The inspector could find no evidence to support that this had been attempted or a reason as to why this was not being done. The care review indicated that intermediate care is not provided and the management team confirmed this. Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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. Not all of the of the individual plans for residents are being reviewed monthly. Residents health care needs were met and medication was appropriately handled and administered by staff. Residents are supported with dignity and their privacy is respected. EVIDENCE: Of the plans of care sampled, half were reviewed monthly and half were not. However, all of the files sampled had fairly new plans of care in place, giving evidence that all residents have had new plans developed over the last few months. It was pleasing to see that many of the risk assessments were signed by the individual resident and that there was evidence that they and their family have been involved with developing these plans. A health care professional was seen visiting in the home during the inspection. They provided mixed, positive and negative feedback on the home and the Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 11 level of care provided, but were pleased to state that some improvements have been noted over the last few months. There were no gaps noted on the Medication Administration Record (MAR) charts and the home has implemented a new system for checking that medication has been correctly administered. If any gaps are noted in the records, senior staff address this with the staff member involved and record any action taken. It was stated that the home has a number of new staff members in place and they have not completed their medication administration training as yet. Senior staff have been given extra time to administer medication on these units and this was seen in action. A staff member discussed the home’s procedure for administration of medication and this was in line with the Pharmaceutical guidelines. 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. Some residents stated that staff are polite and kind, respect their privacy and that they are treated with dignity at all times. One resident stated that staff offer her choices in all aspects of her life. A requirement has been made. Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Service users stated that the activities provided satisfied their social, religious and recreational interest and needs. The home assists services users to maintain contact with relatives and friends. Service users are encouraged to make choices. The meals served are of a high standard and are specifically prepared to meet the service users’ needs. EVIDENCE: The home has employed an activities organiser and a programme of the activities provided showed that there were activities planned for the morning and the afternoon during the week days. On the day of inspection, service users were enjoying an opportunity to sit outside in the garden in the warm weather and listen to some music. Many service users were seen joining in with singing and clapping along to the music. Service users who remained on their units were seen in the lounge areas with their carers, taking part in individual activities or were in their rooms. A number of service users who were in their rooms stated they were there out of personal choice. Service users stated that they enjoy the activities provided. A number of the activities Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 13 on the programme were activities that had been stated as preferences in individual plans of care. This was seen as good practice. Many visitors were seen entering the home during the day and some service users went on outings with their visitors. Many service users talked about who visits them and all stated that their visitors had never been told they could not come in to visit. The home holds a church service regularly on one of the units and some service users stated that they attend this or go to an outside church. Service users stated that one of the things they like about living at Birchlands was that they are given choice. One service user stated that she is involved in choosing everything she does or does not wish to do. Some service users were aware of their risk assessments and why they are not able to do some activities as this could injure them. One service user has exercised choice to continue with an activity, even though a risk has been identified. Staff are therefore extra vigilant and remain close by to assist should any problems arise. The kitchen was clean and appropriately stocked. The chef-manager discussed the menus and the choices provided with the inspection team. All of the comments were made in regard to the food provided were positive. Service users stated that they liked the choices, the variety of the menu and the quality and quantity of food. It was noted that some service users were taking a late breakfast and this was fully accommodated by the home. A service user stated that they prefer to eat their meals in their bedroom. It was pleasing to hear that the chef-manager had won an award as the Anchor Homes Chef of the Year and photographs were seen of the winning menu and the presentation of the prize. This is a competition between chefs and cooks from Anchor homes around the country. The chefs had to prepare a well balanced menu that was nourishing and appealing and was within a specific budget. Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of complaints made to the home has improved. The corporate complaints policy in the home still needs to be reviewed, but a local policy is available. Staff are aware of their responsibilities in the protection of residents. EVIDENCE: A requirement was made at the inspection carried out on 8th February 2006, that the home’s complaints policy must be reviewed to ensure it is suited to the needs of the residents and any complaint must be fully investigated. A timescale of the 31st March 2006 was given and this has been partially met. The manager stated that this is a corporate policy and is currently being reviewed by Anchor Homes, but has not been completed and issued to the home. This was confirmed at a recent meeting between CSCI and the managing director of Anchor Homes. The manager stated that the home has a local complaints policy, advising residents or others to address any complaints directly to the manager or to the senior in charge. From speaking to residents it was clear that they knew who to speak to if they had any concerns or wished to make a complaint. Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 15 The inspectors discussed recent complaints made to the home with the management team, and were informed of the outcomes of these. The home’s management are making improved efforts to respond to any complaint in a prompt and appropriate manner, and aim to resolve any dissatisfaction within the home wherever possible. A number of staff have undertaken training in the protection of vulnerable adults and the prevention of abuse in the care home in recent months and records of these were seen. Staff spoken to stated that they would report any concerns to the manager or senior in charge. Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A programme of planned refurbishment is being developed. All areas of the home were clean, tidy and freshly aired. EVIDENCE: Following a review of the premises last year, the management team advised of a programme of refurbishment that is planned for Birchlands. This will include redecoration of many areas of the home, including the residential units and refitting of equipment such as easy access baths. A new passenger lift was installed in the home last October. The area home support manager stated that the programme has not been finalised yet and a copy will be forwarded to CSCI when completed. It is planned that some of the residential units may be designated for the care of residents with dementia. This will enable the design of colour schemes and Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 17 activities of the units to meet the needs of those residents more effectively. The focus of staff and the staffing of the units will also be arranged to meet the specific requirements of residents. It was clear that the home was clean, free from odours and appeared hygienic. Toilet and bathroom facilities were easily accessible to residents on each unit. The laundry is situated off the main entrance hall and is away from the kitchen and food preparation areas. Hand-washing facilities with liquid soap and paper towels were provided in all appropriate places to maintain hygiene. Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 standard of recruitment practices has improved. Staff receive 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 manager and deputy and have been supported in recent months by a trainee manager. A number of staff have undertaken National Vocational Qualifications (NVQ’s) in care, to level 2 or above. From information supplied on the pre-inspection questionnaire, approximately thirty percent of staff have achieved this qualification. The recruitment records of recently employed staff were seen and contained the required records and documents. It was noted that one member of staff had declared a health condition on the pre employment health questionnaire, Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 19 but no action had been taken in relation to this. It is recommended that any declarations on the pre-employment health questionnaire are referred to Occupational Health department, or a medical reference is obtained, to ensure the applicant is fit for the role they are applying for and will not present a hazard to the residents. 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, dementia care and dining with dignity. The training undertaken by staff is related to the role they carry out. Housekeeping staff and the handyperson for example, have received training in the Control of Substances Hazardous to Health (COSHH), as they are regular users of these products. Induction training records were not available for all of the new staff for inspection. The trainee manager stated that staff take the records to update them and some may have taken them home. These must be retained in the home and made accessible to staff there. This will prevent any loss and ensure that these records are available for inspection, as required. A requirement and recommendation have been made. Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management arrangements at the home must be clearly established and the manager must be registered with CSCI without delay. Residents’ and other monies must be managed more robustly to safeguard against financial abuse. Safeguards must be maintained to protect residents from hazards. EVIDENCE: Due to a period of ill health, the manager has not been able to pursue her application for registration with CSCI and has decided that for health reasons, she will not be able to continue in her current role. The inspectors were advised that the trainee manager, who has overseen the home during the manager’s sickness absence is to be appointed as manager. The current manager will support the new manager for an extended period to ensure a Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 21 smooth transition. The newly appointed manager must apply without delay for registration with CSCI, as the home has been without a registered manager for a year and a half. A survey of the quality of the service provided has recently been circulated to residents and eleven responses have been received, the manager stated. Those seen were positive in their responses and the majority were satisfied, with just a few recurring comments that residents were not offered the choice to self-medicate or retain their own general practitioner (GP). Most had been signed by the individual residents, a small number were anonymous and one had been signed by a relative. The manager advised that a summary of the results will be forwarded to CSCI, once all responses have been received. The carrying out of monthly visits to the home by a representative of the registered provider under Regulation 26 is required and is an effective monitoring tool. Regulation 26 requires the registered provider of the service, to organise an unannounced visit to the service on a monthly basis to check on the quality of the service provided. This must involve speaking to residents, their families or friends and staff, and looking at the premises and the complaints record. A written report must be made and a copy retained in the home. From the documents available at the home, it appeared that the most recent Regulation 26 visit took place in January 2006. The area home support manager stated that she had carried out a Regulation 26 visit since then, but there was no record of this in the home. The administrator stated that monies are held for a number of residents for safekeeping with the administrator managing the monies on a day-to-day basis, and that she is overseen in this by the manager. The amount of money held in the residents’ cash tin was checked with the administrator. It is of serious concern that the amount present did not accurately match the record held. From the record seen, a check of the amounts and records had not taken place with the manager for at least six weeks, since the new record book had been started. The administrator stated that the previous record book was not available for inspection as it had been archived. The home’s petty cash was also checked and it is again of serious concern that the amount present and the record held did not accurately match. The administrator stated that she had loaned a sum of her own money to pay a “cash on delivery” invoice the previous day, but there was no record that this had been authorised by a manager or senior member of staff. Although the petty cash record stated that no cash was remaining, the administrator produced a small amount from a separate tin, stating that she did not wish to leave the home with no cash at all. From this record, the last check of the petty cash by a manager was carried out in January 2006. The management of monies in the home must be carried out more robustly, to safeguard against financial abuse, particularly as this is the second occasion when errors have been noted. Regular checks should be made by two people Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 22 and these should be recorded clearly in the ledgers and record books. It is recommended that record books should be kept available for a period after completion and not immediately archived, as they may be required for reference. Following the last full inspection in October 2005, when similar errors were found in the recording of monies, the area home support manager stated that measures had been put in place to check these during Regulation 26 visits, but there was no evidence to confirm that this had taken place. The health and safety of residents is generally well safeguarded in and around the home although it was noted that a container of an unknown liquid was found stored in an cupboard in a unit kitchen. This was removed to a locked provision immediately. For one resident for whom toiletry products may present a hazard, a lockable bathroom cabinet is required. An immediate and other requirements have been made. Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 1 x x 2 Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 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 2 Standard OP7 OP16 Regulation 15 22 Requirement The residents individual plan must be kept under review and kept up to date. The Anchor Homes complaints procedure must be appropriate to the needs of residents. TIMESCALE UNMET FROM 18/11/05 AND 31/03/06. The manager of the home apply for registration with CSCI. TIMESCALE UNMET FROM 18/11/05 AND 31/3/06 Visits by the registered provider or a nominated person must be carried out in accordance with Regulation 26. A copy of any report under Regulation 26 must be retained in the care home. The amounts of any monies held for safekeeping for, or on behalf of residents, must accurately match the record held. All parts of the home to which residents have access must be kept free from hazards to their health or safety. Timescale for action 09/06/06 11/08/06 3 OP31 9 09/06/06 4 OP33 26 09/06/06 5 OP35 17 Schedule 4 13 11/05/06 6 OP38 11/05/06 Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 25 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 OP28 OP29 Good Practice Recommendations In line with the National Minimum Standards for Care Homes for Older People, it is recommended that at least 50 of care staff are trained to NVQ Level 2 in care. To safeguard residents and applicants, it is good practice to request a medical reference or to refer to Occupational Health, any applicants for employment who declare a medical condition on their pre-employment health questionnaire. Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Birchlands DS0000013569.V288875.R01.S.doc Version 5.1 Page 27 - 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!