Inspection on 14/06/07 for Birchlands Care Home

This inspection was carried out on 14th June 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Birchlands Care Home 15/05/09

Birchlands Care Home 02/06/08

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Birchlands Care Home Moor Lane Haxby York YO32 2PH Lead Inspector Anne Prankitt Unannounced Inspection 14th June 2007 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 Care Home DS0000070001.V343815.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 Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchlands Care Home Address Moor Lane Haxby York YO32 2PH 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) 0115 978 1742 None Mimosa Healthcare (No4) Limited Mrs Judith Cumiskey Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (54) of places Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP 2. The maximum number of service users who can be accommodated is: 54 N/A Date of last inspection Brief Description of the Service: The home is owned by Mimosa Healthcare Limited. Due to a technical change in company arrangements, the service is classed as a ‘new registration’, following a completed application made to the Commission for Social Care Inspection. However, it is an existing service, and this arrangement has made no detrimental changes to the way that the home is run. Birchlands is a purpose built, three storey home providing nursing care for up to 54 people. It is situated in Haxby, close to a variety of shops and amenities. The home currently uses the second floor to provide ‘transitional care’ for up to nine people following discharge from hospital and before being permanently placed in a home. City of York Council makes placements to this unit. The registered manager confirmed at the site visit that the current fees range from £459 to £655 each week. Additional charges are made for hairdressing, chiropody and toiletries. The home provides people with a brochure and service users’ guide, which gives them information about what services it provides. The inspection report is also available at the home for those who wish to see it. Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the site visit, the registered manager, Judith Cumiskey, returned a questionnaire to the Commission for Social Care Inspection. It provided information about the home, including who lives and works there. The inspector also kept a record about what has been happening at the home since the last inspection. Before the site visit, surveys were sent to people who live at the home, relatives and visiting health professionals, so that their views could be sought. The majority of feedback about the service was very positive. Where specific issues were raised, advice was given as to how these could be looked into. Five hours of planning took place before the unannounced visit, which took two inspectors seven and a half hours to complete. The registered manager was on annual leave so was not available. Time was spent at the site visit talking to some of the people who live at the home, the deputy manager, staff and relatives. A tour of the communal areas was taken, a sample of private accommodation was seen, and a sample of documents was looked at. All of the information was used to form a judgement about what sort of service Birchlands provides to the people who use it. Feedback was provided to the deputy manager at the end of the site visit. What the service does well: People who are thinking of living at the home have their needs assessed before they are offered a place. This helps to check that the home will be able to meet them. People are offered care by a staff team who receive regular training to help them understand how care should be provided. People who live at the home commented ‘I get help when needed’; ‘The staff are very friendly and caring’. The environment is kept clean and tidy so that it is pleasant for the people who live there. People are able to maintain important links with their family and friends, who are made welcome by staff. Relatives’ positive comments about the service included: ‘The home is a warm and friendly place with kind and caring staff who help my relative through their final years with compassion and humour’, Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 6 ‘Birchlands looks after my relative very well. Staff are excellent and always prepared to listen’. The registered manager seeks the views of people with an interest in the home. She takes complaints and concerns seriously, and takes action to look into the matters raised, so that they can be resolved. People can be assured that their personal monies looked after by the home will be looked after properly, and will be kept secure. What has improved since the last inspection? What they could do better: Whilst people’s health needs are met, better reflection on what makes them unique individuals could assist in making their care more personalised, and associated risk better understood. Medication looked after by staff could be better audited, so that unnecessary shortfalls are identified sooner. Staff could report concerns to the registered manager sooner, so that they can be properly addressed and dealt with. The risk from cross infection could be reduced by better organisation of the commode equipment that is made available for use. Staff could have a better understanding of their responsibilities in reporting allegations of abuse, to help protect people from harm. For the same reason, all necessary checks must always be made on new staff before they are allowed to provide care to people who live at the home. The emergency lighting must be repaired so that it is in full working order, and so that corridors used by people who live at the home are kept adequately lit. Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 7 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 Care Home DS0000070001.V343815.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 Care Home DS0000070001.V343815.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): 3 and 6. People who use the service experience good quality outcomes in this area. They can be confident that their needs will be assessed before they are admitted, to check that they can be met. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: A senior member of staff meets people to assess their care needs before they are admitted. Information about their needs is recorded, and care is taken to collect information from other sources, such as the hospital or care manager. The information gathered is used to check whether the home can meet the needs of the person concerned. The information is used to develop the care plans following admission. Staff spoken with were satisfied that the information that was collected before a person was admitted helped them to anticipate the care that they would need. The majority of those who returned their surveys were satisfied that they had been given enough information about the home before they moved in. Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 10 The home does not provide intermediate care. The top floor of the home is used as a transitional care unit. The beds are block purchased by social services, from which all referrals originate. Staff responsible for the pre admission assessment of people admitted to this floor said that the dependency of existing people on the unit has to be considered very carefully when carrying out pre admission assessment, because dependency levels can be very high for the staffing numbers. Birchlands Care Home DS0000070001.V343815.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. People who use the service experience adequate quality outcomes in this area. Whilst people’s health needs are met, better reflection on what makes them unique individuals could assist in making their care more personalised. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Each person admitted to the care home has a written care plan. The purpose of the plan is to explain what care the person needs and any associated risks, so that their health and personal care needs can be maintained. Health care needs were generally well recorded. Psychological and mental health needs reported upon did not always focus on the problems of that individual in enough detail. Details about people’s religion and wishes upon dying were sometimes missing. It is difficult for staff to care for the holistic needs of people if this information has not been provided. It makes it harder for them to identify how one person’s individual needs differ from the next, and to understand how they can best be managed. Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 12 Staff also need to make sure that risk assessments are always completed and kept up to date so that they are meaningful. For instance, one person had not had an assessment completed before being provided with bed safety rails. Another person who has a feed directly into their stomach was not properly positioned when in bed. Another had not had their moving and handling risk assessment reviewed after suffering an injury which could affect how staff looked after them. Another person’s rails were not of a suitable height taking into account the pressure relieving equipment that had been provided. Although the deputy manager gave assurance that the person concerned was not at risk, she has now ordered suitable rails. The dependency levels at the home are high. The home has links with, for example, the local surgery, tissue viability nurse, mental health services and dietician. People’s records evidenced that specialist help is requested when problems with care arise. A number of people spend all or part of their day in bed. Therefore available care staff have to be very organised, so that essential care is not missed. People looked well cared for, but some staff commented that they would like to spend more time meeting people’s social needs. They said that sometimes this is not possible, because they are too rushed. However, they strive to make sure that people are cared for and comfortable. The company has provided a range of equipment to make people comfortable, and so that care can be provided safely. Since the last visit, extra specialist beds have been provided, and there was an abundance of hoisting equipment to help safely move those who are unable to mobilise. The home cares for people who, for various reasons, are at risk from choking. However, there is only one suction machine available, which could not be immediately located on the day of the site visit. The deputy manager agreed to take immediate action so that staff always knew where the equipment could be found should it be required. She is now planning to obtain an extra machine which will give staff easier access in the case of emergencies. Staff displayed a respectful attitude towards the people they cared for. They made sure that care was given in private, so that people’s dignity was maintained. The registered manager takes steps through supervision to tackle issues such as staff attitude. A person who lives at the home raised one such matter on the day of the site visit. This was reported to the deputy manager, who agreed to investigate the issue brought to her attention. Further feedback from the area manager following the site visit confirms that this is currently being addressed. Trained staff look after medication on people’s behalf, and the systems in place for managing this safely were generally satisfactory, although an audit of the medication identified a discrepancy between one person’s medication and their records. Another person’s pain relief had run out three days earlier, because it not been reordered in time. Advice was given about the appropriate storage of one medication which needed to be kept below the temperature of the room, Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 13 and about the need to make sure that creams, as well as oral medications, are signed for on the administration records. This was not always the case. The registered manager must review how the system is audited. This will assist in making sure such problems are identified earlier. There has been one medication error reported to the Commission since the last inspection. The registered manager has explained what action has been taken in response to the incident, and there have been no further errors reported. The management at the home are responsive to feedback. The overwhelming majority of relatives agreed that the care delivered is good. The majority of people who live at the home, and who returned their surveys, agreed that staff act and listen to what they say. They said that they always or usually receive the care that they need. Attention given to the points raised will further improve the quality of life for people who live at the home. Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. People can maintain important links with their family and friends, but the routine of the home sometimes places restriction upon choice. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: There is an activities co-ordinator available three days each week. She provides a range of group activities which take place in the home. There are also occasional trips out for those who are well enough to join. Some people recently enjoyed a trip to the local pub, have enjoyed visits by ‘Pat a Dog’, and the hairdresser visits regularly. There is a church service each month, which assists people in meeting their spiritual needs. From the surveys returned and discussion at the site visit, it would appear that the provision of activities for those people who are blind, or who remain in bed, are limited, or seen as ‘not applicable’, and there was a difference in opinion overall as to whether there were activities especially for these people. Staff agreed that the time they have to spend with such people, other than when direct care is being given can be limited. One said ‘There’s nothing for people in their rooms really’. However, the registered manager has provided evidence to show that there is an individual activities plan in place for each person, Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 15 including those who remain in their room. But she has agreed to carry out an audit to check that everyone who lives at the home has access to activities of their choice, and to meet their individual needs. Visitors are welcomed at the home at any time. Comments included ‘We are always greeted with a smile’, ‘Friendly homely atmosphere’. Staff try to accommodate the individual choices of service users. For instance, the chef provides a variety of different meals at mealtimes at people’s request. But the routine of the home does sometimes impact on choices in people’s daily lives. For instance, on the transitional unit, the time at which people can be helped to bed is dictated to some degree by when there are two staff available. Mealtimes are very organised. General assistants are employed, who give assistance to people who attend the communal dining areas for their meals. Staff make sure that people who need help are given individual attention so that their meals are not rushed. Many people remain in bed for their meals. The chef demonstrated a good understanding of dietary needs, because he has access to people’s dietary likes and dislikes assessment, which is kept in their care plan. People were seen to enjoy their meal, although the pureed meal could have been better presented by the staff who served it from each satellite kitchen. However, they were not offered any condiments. Those spoken with agreed that fresh fruit was not normally offered to them, and there was not enough in the store to offer people. Breakfast, lunch and tea is provided. People are offered supper and an evening drink. The registered manager continues to monitor this to check that this happens each evening. Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience adequate quality outcomes in this area. The registered manager responds quickly to complaints and allegations, but this could be delayed if staff do not inform her when they have concerns. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed in a public area of the home. The registered manager keeps a record of complaints made to her. They include details of the complaint, and of the outcome following her investigation. There have been two complaints and one concern raised with the home since the last inspection. There was a record of the response to the complainant in each case. One of these had originally been referred to the Commission for Social Care Inspection. Staff were generally clear about their responsibilities in passing on concerns. However, a delay in reporting a concern about staff attitude had caused further unnecessary upset for the person concerned. The deputy manager agreed to investigate the matter, and further feedback from the area manager confirms that this is now being looked into. There have been two safeguarding adult referrals made to the local authority for investigation. The first, referred by the hospital, referred to a specific care Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 17 need of an individual person. The investigation concluded that the correct care had been given by the home. In the second investigation about an isolated incident regarding staff attitude, the home took proper action to protect people who live at the home until the matter had been investigated in conjunction with the local authority. The outcome concluded that there was insufficient evidence to uphold the allegation made. The majority of staff were very clear about their responsibilities in passing on information about possible allegations. They understood that they were not in a position to keep secrets where people raised concerns. However, two staff spoken with were not. Further training has been organised, which these staff must attend. Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 18 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. People who use the service experience adequate quality outcomes in this area. People live in pleasant surroundings, but their environment could be made safer through improved management of infection control and health and safety. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home was clean and tidy, and provided warm and comfortable surroundings for people to live in. The majority of bedrooms are single. The deputy manager said that whilst there is no policy for use in the case where people share, she and the registered manager make sure that this is properly discussed with all concerned during the pre admission assessment. A maintenance man is employed to carry out in house checks of equipment to keep it safe and fit for use. He is currently carrying out some general redecoration to brighten up the environment. This includes the decoration of some people’s bedrooms, which looked very pleasant. Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 19 The maintenance man checks the hot water temperatures monthly. The temperature to one top floor bathroom checked at the site visit was too hot. This was rectified by him immediately. The records seen showed that this was an unusual occurrence, as the temperatures are normally satisfactory. The emergency lighting to one area of the home has not been in full working order for some time, and there was no evidence that a report sent to the company in November 2006 has been acted upon. Assurance was given that, in the case of fire, the lighting would remain functional. But under normal everyday circumstances one corridor area is not properly lit because of the fault. This could cause safety problems for those people and staff who use it. This must be rectified. The deputy manager took action on the day to organise its repair. Subsequent feedback from the area manager confirms that arrangements have now been made for the work to be completed. The majority of bathrooms are used as storage areas, because storage space is limited. This means that staff have to remove all of the items, including commodes and hoists, into corridor areas before the bath can be used. This situation is not ideal, but the deputy manager said that care is taken so that the corridors are not blocked. The ‘glideabout commodes’ are removed from people’s bedrooms during the day and stored communally. Although the deputy manager gave assurance that there are enough commodes for people to be allocated one each for their own use, this does not happen in practice. This could increase the risk from cross infection. All staff receive training in infection control. The laundry facilities are suitably equipped. People spoken with on the day of the site visit were pleased with the laundry service. Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. Although staff are well trained, they may be restricted in their ability to deliver person centred support. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: There are three floors on which care is provided. Staff are normally allocated to a specific floor. This helps them to get to know people’s needs, which are often multiple and complex. Staff all agreed that they had sufficient time to meet general care needs, but were very busy. Comments included ‘Needs are met, but staff are run ragged’, ‘We would like more staff so that we could spend more time with people. They appreciate it when we can’, ‘The care can be mechanistic. We would like more time for ‘add ons’. The current dependency levels at the home must be seriously considered when deciding upon future admissions to the home, so that the staffing levels allowed by the company are sufficient to cater for increasing dependency. A single person works alone on the transitional unit at night. This unit houses less people than the other floors, but they often have complex needs, and normally require the care of two staff. This arrangement is not ideal. Staff said that it placed restrictions on people’s choice regarding bed times. It could Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 21 also lead to a delay in people getting the care that they wanted, and comments suggested that this had already occurred. The company provides a good training package for staff. The administrator is now responsible for the co-ordination of training. She has put robust systems in place so that staff will not miss mandatory training. She is currently organising sessions so that people who have fallen behind will soon be brought up to date. ‘Safeguarding adults’ training is also classed by the company as mandatory training, and was planned for the near future. This will help to make sure that current gaps in understanding of responsibilities can be addressed. Care staff are encouraged to completed National Vocational Qualifications in Care. There is a rolling programme in place for this to be achieved. Some care staff are currently working towards the accreditation, whilst others were waiting to commence their course. Distance learning is also provided, such as dementia care, and medication update, where the need has been identified through the supervision programme that the registered manager has developed. Trained nursing staff also have the opportunity to attend courses to update their professional practice. Two recruitment files were seen. In both cases the registered manager had made sure that the Criminal Records Bureau check had been returned before the staff had been deployed. However, in one case, the member of staff had commenced duty, and was working unsupervised, before the second written reference had been returned. Staff spoken to, and who had recently been recruited, explained that they received an in house care, and health and safety, induction. This is good practice, but the content of the induction is not recorded. In one case, the induction had been provided, but not signed off the person’s record as having been completed. As this is the immediate induction that staff get before the ‘Skills for Care’ induction, which is arranged periodically, it is recommended that a proforma be introduced. The registered manager can then be satisfied that all newly recruited staff receive a similar induction in both content and quality, and which meets with her approval. Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. The registered manager collects the views of other when making decisions upon how the home should be run. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The registered manager is suitably qualified to run the care home. She is registered with the Commission for Social Care Inspection, and she has completed her Registered Managers Award. She is responsive, and she is actively seeking the views of people who live at the home, their relatives, and staff, to find ways in which the home can be improved upon. Where she has the power to do so she takes action to make the home a better place for people to live in. Staff said that she operates an open door policy. Their remarks included ‘It’s a nice team here. We can ask each other and work Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 23 together’, ‘The manager is supportive and listens’. One relative commented ‘Cracking place’. The registered manager has had a good response from a recent survey sent to relatives about some aspects of the care home. She has just collected the views of the people who live at the home, which she will be looking at collectively on her return from leave, to see where any changes need to be made. The home can look after people’s personal allowances on request. They are kept locked away securely, and the administrator makes sure that the records relating to these allowances are kept up to date. She keeps each person’s money separate, and they can have access to it at any reasonable time. From the information provided before the site visit, and a sample of records seen, it could be evidenced that, generally, the maintenance of the home is kept up to date. The maintenance man stated that outstanding works to the fire equipment and check of the portable appliances are in hand. However, as discussed in ‘Environment’, the emergency lighting needs to be properly repaired so that the corridor is properly lit, and the system in full working order. Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 Specific information must be included in the care plan so that staff have written information about the individual holistic needs of people, and risks associated with their care, to assist them in making care more person centred. The risk assessments identified as missing or in need of update must be completed and kept under review, to check that the people concerned are receiving care in a safe way. The registered manager must review the way in which the medication system is audited, to check that shortfalls in practice are avoided and to make sure that people get the medication they have been prescribed. Timescale for action 31/08/07 2 OP7 13 14/06/07 3 OP9 13 31/07/07 4 OP10 OP16 12 The concern raised by the person 14/06/07 identified at the site visit must be looked into to make sure that their care is being provided in a respectful and dignified way. Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 26 5 OP18 13 The registered manager must make sure that staff at the home understand their responsibilities in reporting allegations, so that unnecessary delays in investigation can be avoided. The emergency lighting must be restored to full working order so that the affected corridor is better lit. To reduce the risk from cross infection, the practice of providing communal commodes must cease, and a system must be devised so that people are allocated a commode for their sole use. The registered person must check that the way that staff are currently deployed at the home allows care to be provided in a person centred way, and which takes into account the collective dependency levels. The registered manager must make sure that all necessary recruitment checks are completed before the staff member concerned is allowed to care for people. 14/06/07 6 OP19 OP38 13 15/07/07 7 OP26 13 14/06/07 8 OP14 OP27 18 31/07/07 9 OP29 19 14/06/07 Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations Based on the difference in opinion about the activities that are available at the home, an audit concentrating on activities should be completed, to check that everybody who lives at the home has access to suitable activities of their choice. It would be good practice to keep a record of the content of the in house induction completed by the home, so that the registered manager can be assured that all aspects of induction have been completed to her satisfaction. 2 OP29 Birchlands Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Care Home DS0000070001.V343815.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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