Inspection on 21/04/05 for Birchlands

This inspection was carried out on 21st April 2005.

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 11/05/06

Birchlands 17/10/05

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 Barley Mow Road Englefield Green Surrey TW20 0NP Lead Inspector Sandra Holland Unannounced 21 April 2005 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Birchlands Address Barley Mow Road Englefield Green Surrey TW20 0NP 01784 435153 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Anchor Trust, 1st Floor, 408 Strand, London, WC2R ONE To be confirmed. Care Home (CRH) 51 Category(ies) of Old age, not falling within any other category registration, with number (OP), 51 of places Dementia - over 65 years of age (DE(E)), 14 Physical disability over 65 years of age (PD(E)), 12 Birchlands Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 51 service users up to 14 may fall within the category DE(E) and up to 12 may fall within the category PD(E). 2. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Date of last inspection 26 November 2004 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 Version 1.10 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 year April 2005 to March 2006 and took place over seven and a half hours. The inspection was carried out by Mrs. S. Holland, Lead Inspector for the service and Mrs. V. Bulbeck, Regulation Inspector and Mrs. M. Wood, Home Manager was present representing the service. A full tour of the home took place and 23 service users and 13 members of staff were spoken to. A number of records were examined including, care plans, staff personnel files, medication administration records and policies and procedures. This was a positive inspection and the inspectors would like to thank the service users, manager and staff for their hospitality and assistance during the inspection. What the service does well: What has improved since the last inspection? Work to improve the odour in the home has been successful in most areas. Staff are now signing the daily communication book entries to confirm that messages have been conveyed and to improve communication. Birchlands Version 1.10 Page 6 The manager is prioritising and planning actions to be taken to address areas of weakness in the standards of service provided. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Birchlands Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Birchlands Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 There is inconsistency in the assessment of service user’s needs and it is not always clear whether service users have been involved in the assessment process. EVIDENCE: Pre-admission assessments were not available within service user’s individual plans even for the mostly recently arrived service user. A care plan was seen that had been drawn up six weeks after the service user had entered the home and was lacking in detail and essential risk assessments. Birchlands Version 1.10 Page 9 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 standard(s) 7,8,9,and 10 An individual plan of care needs is established for each service user, however these require thorough review and revision, both to ensure that they accurately reflect the service user’s needs and to ensure that they are in a format that is clear. Appropriate procedures for dealing with medication are in place and some good practice in relation to this was observed, although one shortfall in the standard was noted. Service users spoke favourably of the care they receive and of the support of the staff. EVIDENCE: The plans of care that were seen were not clear or consistent, were not up to date and did not reflect service user’s needs; there is inadequate recording of the contact details of the next of kin of service users; risk assessments that were seen did not highlight high risk areas such as service user’s aggression, smoking or risk of falls. The manager advised that a number of health care professionals, including General Practitioners (G.P.’s), community nurses and Community Psychiatric Nurses (C.P.N.’s), visit the home to address service user’s health care needs. A chiropodist also visits the home on an “as required” basis, however a number of service users were observed to be in need of chiropody treatment. Birchlands Version 1.10 Page 10 The administration of medication was seen to be carried out satisfactorily and good practice was noted in the transcribing of medication details that were not printed on the medication administration record (MAR) sheets. The receipt of all medication must be recorded and receipt of controlled drugs must be recorded immediately in the Controlled Drug register, as examination of the medication storage facilities revealed that a medication had been delivered to the home, but had not been recorded. Staff were observed to treat service users with respect, with appropriate interaction and seen to knock before entering service user’s bedrooms. A service user who prefers to lock her bedroom door was able to do so. Birchlands Version 1.10 Page 11 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 standard(s) 12, 13 and 14. The day-to-day routines of the home are flexible and service users are able to make choices as to how they spend their time. Organised activities such as carpet bowls, bingo are only carried out on three days a week. Service users are free to develop relationships of their choosing and to interact with other service uses. Visitors to the home are welcomed and service users can meet with their guests in their bedrooms, the unit lounge/dining rooms or the main lounge. A pay telephone is provided in a booth in the reception hall. Service users are encouraged to manage their own affairs for as long as they wish, or are able to do so, and are invited to bring personal possessions into the home. EVIDENCE: Service users were observed relaxing in their bedrooms, on the upper landing seating area and in unit lounges/dining rooms. Some were reading, listening to music, watching the television and chatting to other service users. One service user was enjoying an art activity and another was having a late lie-in. Birchlands Version 1.10 Page 12 A number of family and friends were seen to visit the home. Service users spoken to stated that they would like to attend a greater selection of organised activities if they were available and this was confirmed by the responses to a service user survey, carried out in February 2005. Care plans seen did not record service user’s leisure or social interests. The manager advised that recruitment for a full-time activities coordinator is planned. Service user bedrooms were personalised with pictures, photographs and ornaments and the administrator confirmed that some service users handle their own day-to-day affairs. Birchlands Version 1.10 Page 13 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 standard(s) 16. A complaints procedure is available and service users feel confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: The manager confirmed the process taken to address complaints and was able to give a specific example how she had addressed a complaint, of the actions taken to prevent a recurrence and of other agencies involved if necessary. Service users spoken to stated that they felt able to tell staff of their concerns or of any complaints they may have. The complaints procedure was seen and requires the address and telephone number of the Commission For Social Care Inspection (CSCI) to be included. A number of cards and letters were also seen to contain complimentary and positive comments. Birchlands Version 1.10 Page 14 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 standard(s) 19, 20, 21, 22, 23, 24, 25, and 26. The overall standard of the environment within the home provides service users with an attractive and homely place to live, although not having a maintenance person or gardener in post at present, has resulted in some areas of the home and garden requiring attention. Equipment to aid service users and a call system are fitted throughout the home. The majority of the home was well-aired and odour free. The hand washing facilities in the home are not hygienic. EVIDENCE: A tour of the whole premises, both internal and external, was undertaken. The standard of furnishings provided was good, with each bedroom having matching wardrobes, chest of drawers (with a lockable drawer) and bedside chest. Most bedrooms also had coordinating bedspreads and curtains and have been personalised with photographs, pictures and ornaments. Birchlands Version 1.10 Page 15 Lounge areas are equipped with a number of armchairs, some of which are electrically operated for specified service user’s mobility needs. Other aids to mobility such as grab rails, ramps, raised toilet seats and hoists were available in appropriate places around the home. A lift is available to ensure service users have access to all areas of the home and was seen to be in use. The call system was tested and found to be effective. The courtyard area to the rear of the main lounge does not present as an attractive useable space, or view for service users, as it contains a number of inappropriate items. It is enclosed by wire-link fencing with a gate, which was left open. It was evident that this space is being used as a smoking area. Clean clothing on hangers was airing on the fence even though rotary clotheslines are provided outside this area. Used fire extinquishers and a rusting, sack trolley were also in the courtyard. From the open gate, the drive leads round to the main driveway of the home and the road. Clinical waste and other waste bins are stored in the driveway. The lack of an appointed maintenance person is evident in a number of areas, including a toilet, which has a broken window blind, a sluice cupboard with an inappropriate closure (non-lockable), and replacement brackets are required for some fire extinquishers to affix to the wall. Similarly, the lack of a gardener in post has resulted in the garden becoming overgrown. Odour control in the home has been generally improved but continues to be a problem in a very small number of bedrooms, (one of which had been vacant for a week). In the reception area, the smell of cigarette smoke was noted, arising from smokers sitting just outside. Excess items of furniture and spare wheelchairs were observed to be stored inappropriately in bathrooms. In many areas of the home including bathrooms, toilets and kitchenettes, liquid soap dispensers are fitted but did not contain any soap. Although most staff and visitors to the home gain access via the main entrance, some staff were seen to access the building via the open rear gate/courtyard/laundry room. It was stated that service users occasionally use the courtyard area and access it through the laundry room and that “care has to be taken because of the steps”. Birchlands Version 1.10 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 and 30. The policy and standard of recruitment and vetting practice in the home requires review to ensure that all appropriate checks are carried out. Staff training and development in the areas of induction, care planning and risk assessing is required. EVIDENCE: The recruitment policy available was very dated and did not reflect current practice and from the staff personnel files examined, it was evident that not all the documentation required in Schedule 2 of The Care Home Regulations 2001 (as amended) had been obtained in all cases. From examination of service user records (care plans and risk assessments) and discussion with staff, it was also evident that training is required in these areas to ensure that staff are competent to carry out their roles. Birchlands Version 1.10 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38. The appointed manager has been in post since November 2004 and has developed an understanding of the areas in which the home needs to improve. Health and safety requirements are not being adequately addressed in the home and potentially leave service users and staff at risk. EVIDENCE: The manager stated that she has resubmitted her application to the CSCI for registration and that she has many years experience managing care provision for older people. She advised that she has been identifying areas of the service provision that are not meeting the required standard and is prioritising actions to address these. Observation of the premises and records in relation to health and safety were examined and confirmed that: Fire alarm testing and drills have not been carried out at the required intervals; some fire extinquishers are not retained in the correct position; Birchlands Version 1.10 Page 18 sharp items are not disposed of or stored appropriately; hazardous substances are not kept in a locked provision and Control Of Substances Hazardous to Health (COSHH) advice sheets are not stored with the substances to which they refer. The risk assessments for identified risks such as service users who smoke, who have a history of falls or who are known to be aggressive that were seen, were out of date and for others, had not been completed. A risk assessment of the whole premises in respect of fire must be carried out and fire alarm testing must take place on a weekly basis and be recorded. Completed accident record sheets are not currently filed in service users care plans. Birchlands Version 1.10 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 1 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 2 3 2 3 3 3 2 STAFFING Standard No Score 27 x 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x x x x x x 1 Birchlands Version 1.10 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement Accommodation must not be provided to a service user at the home unless the needs of the service user have been assessed by a suitably qualified or trained person. Appropriate consultation must take place with the service user or their representative regarding the assessment, with confirmation provided in writing that the care home is suitable to meet the health and welfare needs of the service user. The service users plan must be kept under review and up to date. CARRIED FORWARD FROM 26/11/2004. Arrangements must be made for service users to receive where necessary, treatment, advice and any other services from any health care professional. The receipt and disposal of Controlled Drugs, including Temazepam, must be recorded in the Controlled Drugs register. A programme of activities must be drawn up in consultation with service users. A system of recording Version 1.10 Timescale for action 30 May2005 2. OP4 14 30 May 2005 3. OP7 15 30 May 2005 30 May 2005 4. OP8 13 5. OP9 13(2) 20 May 2005 10 June 2005 10 June Page 21 6. 7. OP12 OP19 16 23 Birchlands 8. OP22 23 9. OP26 13 10. OP29 19 11. OP30 18 12. OP38 13 maintenance repairs and requirements must be established to ensure that the care home is kept in a good state of repair internally and externally. Appropriate storage facilities for the purpose of service users and the care home must be provided. Suitable storage facilities must be provided for the use of service users and for the purposes of the care home. Suitable arrangements must be made to prevent infection, toxic conditions and the spread of infection. Persons must not be employed at the care home unless all the information and documentation specified in Schedule 2 of The Care Home Regulations 2001 (as amended). CARRIED FORWARD FROM 26/11/2004. Persons employed to work at the care home must receive training appropriate to the work they are to perform, including structured induction training. All parts of the home to which service users have access must, so far is reasonably practical, be free from hazards to their safety. Unnecessary risks to the health or safety of service users must be identified and so far as possible be eliminated. The security of the premises and access to it must be reviewed to prevent service users being harmed or being placed at risk of being harmed. 2005 10 June 2005 20 May 2005 20 May 2005 10 June 2005 20 May 2005 Birchlands Version 1.10 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations It is recommended that a photograph of each service user should be placed on the medication administration record (MAR) divider card and on the care plan to ensure accurate identification of service users and reduce the risk of medication administration errors. Taps that automatically turn off should be fitted in those service user bedrooms where there is a risk of flooding. 2. 21 Birchlands Version 1.10 Page 23 Commission for Social Care Inspection 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 Version 1.10 Page 24 - 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!