Inspection on 02/06/08 for Birchlands Care Home

This inspection was carried out on 2nd June 2008.

CSCI found this care home to be providing an Good service.

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 14/06/07

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Birchlands Care Home Moor Lane Haxby York YO32 2PH Lead Inspector Paul Newman Key Unannounced Inspection 2nd June 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Birchlands Care Home DS0000070001.V365033.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.V365033.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) 01904 760100 01904 765050 birchlands@mimosahealthcare.com 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.V365033.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 The maximum number of service users who can be accommodated is: 54 14th June 2007 2. Date of last inspection Brief Description of the Service: Mimosa Healthcare Limited owns Birchlands. It is a purpose built, three storey home providing nursing care for up to 54 people and 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 £524 to £690 each week. Additional charges are made for hairdressing, chiropody and toiletries. The home provides people with a brochure and service users’ guide that 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.V365033.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The accumulated evidence in this report has included: • • • • • • The previous key inspection. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. Relevant information from other organisations. What other people have told us about the service. Information obtained from people living at the home, relatives, staff and other health care professionals. One inspector made an unannounced visit to the home that lasted seven hours on 2 June 2008. We were aware of the manager’s leave arrangements and since she was not present at the last inspection, the visit was planned so she was likely to be at the home. Before the inspection visit, the manager was sent an Annual Quality Assurance Assessment (AQAA) to complete. This is a self-assessment that if completed properly, should give us a lot of information about how the home is operating, what improvements it has made and what is planned for the future. It tells us where we can find evidence that the home is meeting National Minimum Standards. The AQAA that was returned was clear and gave us good information that helped plan the inspection. During the visit, a number of documents were looked at and all areas of the home used by the people living there were inspected. Apart from spending time with the manager, a good proportion of time was spent speaking to the nurses, other staff, people who live at the home and visitors. Time was also spent in communal areas and the dining rooms, watching what was going on and checking whether people appeared comfortable and cared for. Surveys were sent out before the inspection visit for people living at the home, relatives and friends, healthcare professionals and staff to express their views on how things operate, the services and care provided. At the time of writing this report, surveys from seven people using the service, three relatives, two healthcare professionals and seven staff have been returned and the general feeling expressed was a high degree of satisfaction. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 6 Feedback was provided at the end of the inspection to the manager. What the service does well: What has improved since the last inspection? The AQAA that was returned indicated that the requirements and recommendations made in the last inspection report have been acted upon. It also provided good information about the improvements made and there was evidence to support this during the inspection visit. It has been a good and productive year. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 7 The home has: • Reviewed and updated the written information about the home that now reflects it is a non-smoking home. • Continued to train staff on pre-admission assessments to increase confidence about making decisions about whether the home can meet a person’s needs. • Provided training and supervision sessions to staff on writing better care plans. The company has introduced a new auditing tool of care plans, and this has improved the standard of the care plans. • Introduced the Liverpool Care Pathways for the dying, and provided training for both nursing and care staff on this. Additional training has been undertaken by some of the nursing staff on palliative care. • Been successful in obtaining a government grant to upgrade the dining room facilities on the first floor, to improve the dining experience for people. • Appointed an enthusiastic activities organiser who has increased opportunities for groups and individual people. • Introduced theme days, which involves decorating the home and special menus. • At the request of the people living at the home a monthly newsletter has been introduced. • A more robust medication audit has been introduced. • Provided a disabled access shower room. • Provided a keypad door entry system, to protect clients and staff from intruders. • The lighting levels have been increased in some of the darker corridor areas. What they could do better: This was a positive inspection with all of the issues raised in the last inspection report addressed. One new requirement is made based on the collective evidence of surveys, conversations with staff and observations made during the inspection visit. There was sufficient evidence from surveys from residents, relatives, healthcare professionals and staff to indicate that staffing levels are not always adequate and staff going sick at the last minute can cause this. Dependency levels of residents are high and the manager must make sure that sufficient numbers of staff are on duty to make sure peoples needs are met at times when they want or need them to be. Three recommendations are made. One follows on from the requirement about staffing, the other two in connection with care plans: Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 8 • • • The company may well consider reviewing and increasing staffing levels. This will further enhance the opportunities and quality of life for people. The AQAA acknowledged that the home wants to continue to develop the care plans in a holistic and person centred way, and this should be achieved. It is this quality and detail that fully evidences that staff are made aware of peoples’ preferences. It was noted that each care need identified in the care plan index was numbered but the written plan of care did not always have the number identified. This should be done so that it is less difficult and time consuming to get straight to a specific plan. 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.V365033.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 does not apply to this home. People who use the service experience good quality outcomes in this area. People have up to date written information about the home to help them decide if the home is suitable for them to live in. People are properly assessed before admission so all concerned can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The surveys that were returned and conversations during the day indicated that people were provided with enough written information about the home. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 11 During the tour of the premises it was noted that up to date service user guides and welcome packs were available in all bedrooms. Four care plans were checked during the day. One of these was for the most recent admission. All had a pre-admission assessment that was supported by additional social work assessments and care plans. Once an assessment has been completed and a positive decision made, a letter is sent out to either the client or next of kin, stating that an assessment has been carried out, who carried out the assessment, and confirms that at the current time the home feels it can meet the person’s needs. On the day of admission, a resident’s agreement is issued, detailing the fees, and how the payments are broken down. It outlines what items are included in the fee and what will be at extra cost like hairdressing, chiropody, newspapers or dry cleaning. From the information gathered in the pre-admission assessment a plan of care is written. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. People who use the service experience good quality outcomes in this area. People get the care they need and the care plans provide instructions and guidance for staff to follow so they are fully aware of peoples’ needs. This includes safe medication practices that make sure people get the drugs that are prescribed for them and addressing the needs for those coming to the end of their lives. People are treated with respect and in a dignified way. EVIDENCE: The AQAA gave detailed information on how the home approached peoples’ care and met their care needs from the point where they were admitted and for those coming to the end of their lives. It also outlined medication practices. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 13 The four case files that were checked showed that information had been accurately used from the pre-admission assessment to draw up the plan of care. People and their relatives spoken with during the visit confirmed that they had been involved. The plans addressed individual health, personal and social care plans. On admission a range of risk assessments are made for moving and handling, nutrition, dependency and pressure sore risk. People have their weight recorded at least monthly and there was evidence to show that any significant changes are referred to the GP who makes a weekly visit. Other healthcare professionals are consulted when required and these include the dietician, tissue viability nurse, and community psychiatric nurse. The speech and language team also do domiciliary visits for assessment and advice on swallowing difficulties. Regular optical, dental and foot care are arranged. The plans offered sufficient guidance to staff for them to know what each person’s care needs are, and how they should go about addressing these. The home has been trying to develop the care plans to make them more ‘person centred’ so that there is a lot more information about peoples’ personal preferences, preferred lifestyle and their life history. There was evidence of this on the files seen. The AQAA acknowledged that they want to continue to develop the plans in this way, and this is encouraged. It is this detail that fully evidences that staff are made aware of peoples’ preferences, although in speaking to people at the home, watching what was going on and speaking to staff, it is clear that they know the people they care for very well. It was also noted that each care need identified in the care plan index was numbered but the written plan of care did not always have the number identified so it was more difficult and time consuming to get straight to a specific plan. Medication procedures and practices were discussed and seen and the storage and the recording of drugs that are administered (including controlled drugs) were checked. No problems were found and practices that were seen were safe. The AQAA had identified that a more robust system of self-auditing had been introduced to check on the safety and recording of the medications administered. Nursing staff who administer drugs undergo an annual competency assessment for administering medications. Meetings are held with the local pharmacy to discuss any issues surrounding medications. The home seeks the views of people about how they would like their care to be delivered especially on the issue of gender when it comes to attending to personal care. All personal care, chiropody, Drs. visits are carried out in the privacy of their own bedrooms. During the inspection, staff were seen knocking on bedroom doors and making sure that doors were closed at times when personal care was being delivered. People spoken to said that that staff are attentive to their needs and wishes, although a some of the surveys suggested that staff did not always attend to people in a timely way. Whilst maintaining peoples’ anonymity, this and any other isolated comments made Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 14 in the surveys were brought to the attention of the manager to use at the next staff meeting. Healthcare professionals and relatives made the following written comments in surveys that were returned: • ‘They show consideration to relatives/friends as well as residents (very helpful/friendly staff who cater well for individual needs like diet)’. • ‘Birchlands always appears to meet individual needs. They are very open to suggestions to achieving personalised care’. • ‘Whilst present at the nursing home, staff are observed knocking on doors and always speak to residents in a polite and courteous manner’. • ‘The home provides good nursing care, listen to and incorporate individual needs/wishes and are open to constructive discussion of improvements to service’. • ‘The home provides sensitive and appropriate care for very dependent residents’. The files showed that information is gained, as far as is possible, from the client and their relatives on their wishes for death and dying. The home has introduced the Liverpool Care Pathways, with the full support of the GP, and several staff members have undergone further training on palliative care. Nursing staff are also trained in the use of syringe drivers, and make sure that all symptoms are recognised and addressed. The home manager is the link nurse with the Community Macmillan Nurse Team and is also the coordinator of the nurse support group. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. Peoples’ social expectations and personal preferences are met and they are able to exercise choice in their lifestyles so they can be as independent as they can. People living at the home are provided with a varied and nutritious diet so they can eat healthily. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The home appointed an activity organiser in February 2008. She was in the home during the inspection and it was immediately noticeable the positive impact of her personality and enthusiasm had on people in the home and the relatives who were visiting at the time. She keeps good records of what Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 16 people’s social needs, likes and dislikes are, and what she does with individuals on a daily basis. It is positive that she recognises the need for both group and individual activities particularly for those people who cannot leave their room. There is a whole range of art/craft activities, including making individual picture books of friends and families, card and bookmark making. There is some gardening going on and people have tomato plants on windowsills. There is entertainment arranged, shopping trips and other outings. The monthly newsletter that has been introduced has been successful and gives everyone connected with the home a flavour of the successes of the previous month, ‘what’s on’ the coming month, staff news, birthdays coming up and other announcements. The minutes of Residents and Family meetings show that people are encouraged to express their views, their ideas and suggestions. It is partly as a consequence of these that people who are unable to come out of their rooms are afforded individual time that might be something like having the newspaper read to them. The organiser has started work on reminiscence, accessing photos from the Internet of York in bygone times, and then doing group work discussing these pictures and memories it brings. Relatives are encouraged to join in or contribute to all activities and the AQAA indicated that they have been so enthusiastic about the improvements that they are donating either their services to help, sing, or provide materials for crafts, and flower arranging. Whilst the manager and organiser have further developments they want to make, these improvements since the last inspection and the momentum created are excellent. Theme days have been introduced where the home is decorated and special menus provided. There had been an Italian theme, the day before the inspection visit. Monthly communion services for Church of England, and weekly visits from Roman Catholic Priest, either as a group or in individual rooms take place. Links have been built with the local community centre who have invited people from the home to luncheon clubs and coffee mornings. The surveys that were returned and comments made during the visit indicate that visitors are made to feel welcome and at one point in one lounge it was clear that visitors who got to know each other enjoyed friendly banter and conversation with each other that added to the atmosphere in the home. There was little focus during the visit on the food provided since the information provided in the AQAA and the positive results of the surveys suggested that people are consulted about the menus, their personal dietary needs and preferences are known and professional advice is sought from the GP and dietician and speech and language team where necessary. The home was successful in obtaining a government grant to upgrade the dining room facilities on the first floor to improve the dining experience for people. The meal seen was not rushed and people got the necessary sensitive Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 17 support that they needed where it was required, in one case by a relative. People said that they had enjoyed the meal and the food was always good. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. The people who live at the home and their relatives know how to complain and feel confident that they will be listened to and that action will be taken when necessary. There are adult protection procedures that staff are aware of through training, so people can be assured that they can feel safe because staff know what to do. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The home aims to deal with situations as they occur, and encourages families to discuss any area of concern with the nurse or manager at the outset. In the conversations with people during the day and in the written comments made in surveys that were returned, this was clearly the normal way of doing things. People felt comfortable about raising things and said that they were listened to and actions were taken. One comment made was, ‘minor complaints have been dealt with efficiently’. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 19 Where formal complaints have been made (three in the last year), these have been investigated under the appropriate procedures, properly documented and in these three cases were not substantiated and the complainants were satisfied with the outcome. The complaints procedure is displayed in reception and also in welcome packs in individual client bedrooms. Protection of Vulnerable Adults training is ongoing for staff and is mandatory training. This is also discussed with staff at supervision sessions held six times a year. A straightforward flow chart is available to staff so that they are aware of the reporting process for abuse. It is simple to follow and has the necessary contact phone numbers for notifications to other agencies. All staff have been issued with the company Adult Abuse Protection Policy and Whistle Blowing Policy. Staff spoken with confirmed that this was the case and that they had undergone training. Other checks made on recruitment, safekeeping all met required standards. medication and money held for Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 20 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 good quality outcomes in this area. People living at the home live in a clean, comfortable and safe environment that is properly maintained and regularly improved. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The tour of the premises found things clean, well maintained, and odour free with the gardens tidy and providing easy access for residents to enjoy the outdoors. Bedrooms were comfortable and personalised and there is an ongoing programme of redecoration and refurbishment. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 21 Since the last inspection the first floor dining room has been fully upgraded, the second floor corridors have been redecorated giving a much lighter open feel to them. The reception area has also been refurbished. A disabled access shower room has been provided offering more choice to people and a keypad entry system fitted to improve security. Although attempts have been made to separate lounge areas and create smaller areas where people can listen quietly to the radio, this was not a success as people preferred things the way they were and asked for them to be returned. But this shows that staff are thoughtful and prepared to try things out for the benefit of people living at the home. The passenger lift is available to all floors. Hoists, and other manual handling equipment is available and slings provided to meet assessed needs of individuals. All laundry is cleansed using a system that provides guaranteed infection control. Washing facilities have also been increased. People spoken with on the day of the site visit were pleased with the laundry service. The home complies with Environmental Health inspections and there are no requirements from the Fire Authority. All staff receive training in infection control and health and safety. The home employs a maintenance person who, apart from general maintenance, carries out regular checks on things like the fire safety systems, emergency lighting and hot water systems. The records of these were checked and found to be well recorded and up to date. He is also responsible for fire drills and comes in at any time of the day so that all staff regularly experience a drill. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 22 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 good quality outcomes in this area. People living in the home are cared for by committed staff who are properly recruited, trained and qualified for the job but sometimes there have not been enough staff on duty to meet the needs of people when they need or request it. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The surveys returned by staff reflected positive views about the training and support provided at the home. There were mixed views in the surveys about there being enough staff on duty and how this might affect the care delivered to people. Some of this was put down to the absenteeism of some staff at last minute and two of the surveys said that management should address this. Some of the surveys returned by residents and relatives also suggested that there might not always be enough staff to deal with things so that people got the right support when they needed it. This was not reflected in the conversations with staff during the visit who expressed that moral was improved and there were generally enough people to get the job done. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 23 Staff appeared committed and certainly wanted to be able to spend more individual time with people but also expressed views about the positive affect of the appointment of the activity organiser on morale in the home in affording people at least some ‘personal quality time’. Observations during the day supported the view expressed in the AQAA that adequate staffing levels are provided. Staff were, in the main, task orientated and focused on personal care with people with high dependency levels. Where staff shortage does occur (although there was none on the day of the visit), it would be easy to imagine (based on experience) that people may have to wait longer than they should for some staff attention. On the basis of the combined evidence there is a requirement that the manager should make sure that staffing levels are adequate at all times. This will make sure that people get the care they need when they want it. The company may well want to consider reviewing and increasing staffing levels. This will further enhance the opportunities and quality of life for people. Nevertheless, from what was seen, there are good relationships, people who looked well cared for, were happy and there was a good atmosphere in the home. Relationships were warm and there was some friendly banter from time to time. Visitors also appeared to be enjoying their time in the home and had good relaxed relationships with staff. The files for the three most recently recruited staff were checked. These showed that staff are not appointed until the required checking and vetting is completed. This makes sure that people are protected from staff who may not be suitable to work in the care industry. The data provided from the AQAA together with training records seen at the home and conversations with staff show that there is a commitment from staff to be trained and there are systems and records to make sure that they are up to date with statutory safe working practice training. Some staff who had achieved National Vocational Qualifications (NVQ) have left over the last year, some of these to do nurse training. But currently there are eight staff working towards an NVQ and the home continues to try and achieve the 50 target for care staff who should have the qualification. The housekeeper has successfully achieved an NVQ in housekeeping. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 24 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 home is well managed and the opinions and interests of the people are central to the way the home is run. Safety checks and systems of communication make sure that the home is a safe place to live. We have made this judgment using available evidence including a visit to this service. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager is experienced and qualified as a nurse and has a management qualification. From the conversations with people, visitors and staff she is considered approachable, encourages new ideas and has high standards of care. Staff feel that they have a clear understanding of what the manager expects from them. A trainee deputy manager has recently been appointed. There are regular staff meetings, individual supervision sessions and staff feel supported. The company has systems of surveying people and their relatives and the results of the surveys were made available during the visit. These are graphically presented and outline written comments made. On a daily basis it was also clear that staff regularly check on the wellbeing of people making sure they are comfortable or if they need anything. There are regular ‘Residents and Family’ meetings and positive comments made by relatives indicate they feel these are useful and productive. The company makes its own quality checks that make sure that the home is compliant with legislation and National Minimum Standards and if not what actions need to be taken. The home’s administrator holds some people’s personal money for safekeeping. She described and demonstrated the systems, procedures and practices for making sure this is properly accounted for and is safe. One person’s records were checked and a cash reconciliation made. People can be assured their money is well looked after and accounted for. Staff were seen to be wearing appropriate protective clothing to prevent cross infection and safety checks are made of the facilities and equipment to make sure the home is a safe place to live. The housekeeper and team do well to make sure the home is clean and free from unpleasant odours. Staff are trained in safe working practices and are up dated regularly. Some records of safety checks were seen (fire) and found to be up to date. Accident records were also checked and were properly recorded and are audited by the manager to check if risks can be reduced. The AQAA confirmed that equipment and facilities are checked regularly to make sure it is in good and safe working order. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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 OP27 Regulation 18 Timescale for action The manager must make sure 30/09/08 that staffing levels are adequate at all times. This will make sure that people get the care they need when they want it. Requirement 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 OP7 Good Practice Recommendations The AQAA acknowledged that the home wants to continue to develop the care plans in a holistic and person centred way, and this should be achieved. It is this quality and detail that fully evidences that staff are made aware of people’s preferences. It was noted that each care need identified in the care plan index was numbered but the written plan of care did not always have the number identified. This should be done so that it is less difficult and time consuming to get straight to a specific plan. The company may well want to consider reviewing and DS0000070001.V365033.R01.S.doc Version 5.2 Page 28 2 OP7 3 OP27 Birchlands Care Home increasing staffing levels. This will further enhance the opportunities and quality of life for people. Birchlands Care Home DS0000070001.V365033.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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