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Inspection on 25/05/07 for Birchville Court Nursing Home

Also see our care home review for Birchville Court Nursing Home for more information

This inspection was carried out on 25th May 2007.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Feedback from people living in the care home and their relatives was positive. Care plans examined showed that individual`s needs were being met and that their privacy and dignity was respected. People living in the care home were complimentary of the staff, food and their rooms. Records were generally maintained in good order. Staff commented that they received appropriate support from management and were happy to be working at the care home. Relevant training was facilitated for them. The management operated an open door policy and is transparent. The home had received 22 compliments since the last inspection.

What has improved since the last inspection?

Good documentation in individual`s care plan particularly in relation to nursing care including pressure areas and catheter care. Risk assessments were undertaken as appropriate. Statement of Purpose and Service Use`s Guide were updated. Regular fire drills were carried out and a list of staff that attended was kept. The home continues to care very well for people needing nursing care. The staff team should be commended for providing a good quality service.

What the care home could do better:

A quality assurance system must be devised and implemented based on seeking the views of people using the service, their representatives, staff and other interested parties. An induction programme for all new staff should be devised and implemented and care staff should receive formal supervision at least six times a year.

CARE HOMES FOR OLDER PEOPLE Birchville Court Nursing Home Heathbourne Road Bushey Heath Hertfordshire WD23 1PB Lead Inspector Bijayraj Ramkhelawon Unannounced Inspection 25th May 2007 10:00 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 Birchville Court Nursing Home DS0000019293.V341964.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. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchville Court Nursing Home Address Heathbourne Road Bushey Heath Hertfordshire WD23 1PB 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) 0208 421 9110 0208 421 9117 birchvillecourtcarehome@tesco.net Peach Glen Limited Mrs Christine Kelly Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home may accommodate 39 older people who require nursing care. 13th June 2006 Date of last inspection Brief Description of the Service: Birchville Court is situated on the outskirts of Bushey Heath. The two storey period building with a modern ground floor extension to the rear is set back from the road in extensive grounds. Visitors parking is provided to the side of the main building. The home has been extensively modernised in the last eighteen months providing accommodation in 39 single rooms many of which have en-suite toilets and wash hand basins. A feature of the home is the overhead-tracking hoists, which have been provided in the bathrooms, shower room and toilets. There is a large lounge, sunroom, conservatory and dining room on the ground floor. The rooms in the older part of the house and the entrance hall are decorated in period style. The current fees charged are £591.58 - £ 750.00 per week. A copy of the ‘Statement of Purpose’ and ‘Service User’s Guide’ is available from the care home. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 25th May 2007 and took one day. Feedback from people living at the care home, visitors and staff was sought during the inspection. A completed pre-inspection questionnaire was received from the registered manager and information from this questionnaire formed part of the overall inspection process. Policies and procedures, a sample of people’s care plans, staff files and other documents were examined. General observation including interaction between staff and people living at the care home, the management and administration of medicines, adherence to health and safety regulations, fire safety and other linked legislation were also carried out. This was a positive inspection. All the requirements and recommendations made in the last inspection were complied with. People living in the care home said that they were being ‘well looked after’ and ‘well cared for’. The staff are ‘nice and caring’. ‘Food is good too and plenty’. What the service does well: What has improved since the last inspection? Good documentation in individual’s care plan particularly in relation to nursing care including pressure areas and catheter care. Risk assessments were undertaken as appropriate. Statement of Purpose and Service Use’s Guide were updated. Regular fire drills were carried out and a list of staff that attended was kept. The home continues to care very well for people needing nursing care. The staff team should be commended for providing a good quality service. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate information is available to people looking to live at the care home so that they can make a decision about the home. Each person at the care home has a comprehensive assessment of his or her needs carried out prior to moving to the home. EVIDENCE: Adequate information was available to people looking for a care home and their relatives so that they could make an informed decision about the home. An up to date ‘Statement of Purpose’ and ‘Service User’s Guide’ were also available at the care home. Care plans examined included an assessment of needs for each person. Reports from other professionals formed part of the care plans. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were detailed and comprehensive. Good care practices and interactions between staff and people living in the care home were observed. The management of medicines was maintained in good order with records kept. EVIDENCE: People living at the care home confirmed that they were well cared for and their individual needs were being met. Good care practices and interactions between staff and them were observed. They were appropriately dressed, well groomed and they confirmed that staff addressed them by their preferred names. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 10 Staff members on duty were observed to deliver care and attend to service users’ needs in a manner that respected their privacy, dignity, choice and wishes whilst actively promoting independence where possible. Personal and intimate care practices were carried out behind closed doors. Records of medicines including the receipt, storage, administration and disposal were kept in good order. Care plans were detailed and comprehensive and included assessment of needs, risk assessments, daily records, weight charts, nutritional assessment, Waterlow chart for pressure areas and relevant information on how individual’s identified needs were being met. A policy and procedures for care of the dying was in place. Staff members spoken said that they were aware of this policy. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home have choice and control over their daily routines and their expectation and preferences in relation to social, cultural, religious and recreational needs were being met. Wholesome, well-balanced and appealing food was served at appropriate intervals and in comfortable surroundings. EVIDENCE: At present day care activities are provided on a planned sessional basis where outside entertainers are booked to perform on days of the week. There is a volunteer day care activity co-ordinator who works one day a week and care staff have been providing some activities and outings as and when possible. The home also accesses ‘Dial A Ride’ transport for taking people out to visit their relatives or to places of interest. Communion is held once a week and the Summer Fayre was planned for 21st July 2007. On the day of the inspection, it Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 12 was noted that people living in the care home were listening to music, reading newspapers, chatting to others and watching T.V. The lunch was observed and tables were laid nicely and a choice of drinks was available at each table. People spoken to were complementary of the food provided. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure that all people living in the care home can access, both formally and informally. Staff have the appropriate training to ensure that people are protected from abuse. People and their families can feel confident that their concerns would be listened to and dealt with. EVIDENCE: A copy of the complaints procedure was available to prospective and current individuals living in the care home. Those spoken to said that they were aware of the complaints procedure but would prefer to speak to a member of staff or the manager if they had any concerns. Staff confirmed that they have received training on Protection of Vulnerable Adults. Two complaints and 22 compliments have been received since the last inspection. Both complaints were dealt with in accordance with the home’s complaints procedure. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was kept clean and generally well maintained. Bedrooms were personalised offering a homely, lived in feel. The buildings and the surrounding grounds were well maintained. EVIDENCE: The home and its surroundings offered a pleasant, comfortable and safe environment to people living in the care home. These were kept clean and generally well maintained. Bedrooms were personalised offering a homely, lived in feel. People spoken to said that they were happy with their bedrooms and other facilities. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 15 The home has adequate number of domestic staff and records showed that staff have been provided with training in hygiene and infection control. One member of staff is delegated as the ‘link person’ for infection control in the care home. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The skills and experience of staff were varied. There was an enthusiastic, dedicated and caring staff team who took great pride in the service provision. Adequate number of staff was rostered on duty to meet the needs of people living in the care home. EVIDENCE: There was adequate number of staff rostered on duty per shift during the day and night. People living in the care home were complimentary about their rooms, staff and food. They said that ‘ staff are nice, they look after us and are very kind’. Staff files examined had all the relevant documents required by this Standard. Staff spoken to confirmed that they have received appropriate training, this included statutory training. 62 of the care staff has successfully completed their NVQ Level 2. It was noted that staff did not have an induction programme. The Manager and the Operational Manager are both aware that Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 17 they should devise and implement an induction programme for all new members of staff. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 18 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, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of people living in the care home was generally promoted and protected. EVIDENCE: Staff confirmed that the registered manager operated an open door policy to staff, people living in the care home and to their representatives. Good professional interaction between staff and service users was observed. Staff confirmed that they had undertaken all the mandatory training. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 19 It was noted that care staff did not receive formal supervision and that a quality assurance system was not devised and implemented. This means that there were no systems in place at the home to routinely develop good care practice amongst staff or for people living at the home to influence to development of the service more generally. All statutory records were available for inspection and maintained in accordance with legislation. These records help the home deliver a safe and consistent service to people living at the home. Staff spoken to were aware that service users can access their records and information held about them in accordance with the Data Protection Act 1998. The home does not manage money on behalf of people living in the care home. There were policies and procedures in place to ensure that the health, safety and welfare of people living in the care home was promoted and protected. These records were accessible to all staff. All accidents and injuries are recorded in the accident book and RIDDOR forms have been completed where applicable. The CSCI has been kept informed of all accidents. A valid insurance certificate (expires on 17/09/07) was displayed in the reception area and this offered cover of no less than £5 million. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 20 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 x 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 3 Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 21 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 OP33 Regulation 24 Requirement A quality assurance system must be devised and implemented based on seeking the views of people living at the care home, their representatives and other stakeholders. Timescale for action 14/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP30 OP36 Good Practice Recommendations An induction programme for staff should be devised and implemented. Care staff should receive formal supervision at least six times a year. Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Birchville Court Nursing Home DS0000019293.V341964.R01.S.doc Version 5.2 Page 23 - 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. 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