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Inspection on 31/01/06 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 31st January 2006.

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

The Registered Manager conducts assessments on service users identifying the needs of service users prior to admission. The care plans drawn up from the assessment and on going knowledge of the service users needs are excellent. They are clear, informative and give an excellent around picture of the needs of the service users and how those needs are to be met. The home care very well for frail service users and make10th August 2005.s every effort to include them in the day to day activities in the home.

What has improved since the last inspection?

The last inspection was positive. The home continues to care very well for service users needing nursing care.

What the care home could do better:

On this inspection the kitchen was in need of a full deep cleaning. The Registered Manager assured the inspector that this would be carried out as soon as possible.

CARE HOMES FOR OLDER PEOPLE Birchville Court Nursing Home Heathbourne Road Bushey Heath Hertfordshire WD23 1PB Lead Inspector Marian Byrne Unannounced Inspection 31st January 2006 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.V282073.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 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 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.V282073.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home may accommodate 39 older people who require nursing care. 10th August 2005 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. Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a positive inspection. The inspector observed good interaction between staff and service users. Service users were appropriately dresses and were well presented. The home caters for very frail service users it provides ‘kirton’ chairs for service users who would otherwise be unable to sit in the sitting room. Kirton chairs provide full support to enable a very frail person to sit comfortably and safely. Risk assessments have been completed to ensure the chairs are being used appropriately. The home admits very frail service users some of whom are in the last stages of their lives and full support to the families of service users. Details of standards not inspected at this inspection are available in the inspection report dated 10th August 2005. What the service does well: What has improved since the last inspection? 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. Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 Page 6 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.V282073.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected. EVIDENCE: Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 & 11. Medication is administered and recorded appropriately. The home manages the passing of life with respect and dignity. EVIDENCE: The home has a room dedicated to the storage of medication. The temperature is controlled and medication including controlled drugs and stored and recorded appropriately. The home endeavours to offer a home for life to service users and the passing of life is respected and support and assistance is offered to the families of the service user. This includes offering meals and the staff being available to the families at difficult times. Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 & 15. Service users have control over their lives where possible. The food served is of good quality and appealing. EVIDENCE: The home endeavours to offer choice and control to the very frail service users where possible. The Registered Manager has purchased kirton chairs to enable service users to be part of the home and to spend time in the communal areas. The kirton chairs offer more support and comfort than conventional chairs and can be easily moved around the home. The use of these chairs means that frail service users have more choice about where they spend their day. The food served on the day of the inspection was tasty and looked appealing. Service uses spoken with confirmed this. Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 & 18. Complaints are listened to and responded to in a timely manner. Service users are protected from abuse. EVIDENCE: The home has a complaints policy that is followed. The Registered Manager operates an open door policy and uses this to defuse any problems by reacting immediately. The home follows Hertfordshire’s Protection of Vulnerable Adults. All service users are registered to vote if they so wish. Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26. In the main the environment was clean and nicely decorated. The home has all the equipment necessary to enhance their lives and assist mobility. Rooms were personalised. The kitchen was in need of a deep clean. EVIDENCE: On the day of the inspection the home, with the exception of the kitchen, was clean and fresh. Bedrooms were decorated and furnished to reflect the personality of the service users. The home has sufficient equipment to assist service users with mobility. The home has an appropriate number of baths to meet the needs of the service users and the demands of the Care Standard Act 2000. Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 Page 12 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30. The home is staffed by an appropriate number of well trained and supervised staff. EVIDENCE: The home follows a robust recruitment procedure. The staffing files inspected contained two references, proof of identity and clearance from the Criminal Records Bureau. All staff receive induction and mandatory training including moving and handling. Where observed, staff assisted service users with mobility in an appropriate manner and the interaction between staff and service users was positive. Service users spoken with informed the inspector that the staff were very gentle, kind and caring. Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 Page 13 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 – 33 & 38. The home is well managed and is run in the best interests of the service users. EVIDENCE: The Registered Manager is dedicated to the care of the service users in the home. She operates an open door policy to staff, service users and to their representatives. She provides strong leadership and management that protects the welfare of the service users. She is proactive in ensuring staff are aware of their duties and is fully aware of the extent of her responsibilities within the home. The home is run in the best interest of the service users and the manager is available to the service users and their families and representatives. The home ensures all equipment is serviced regularly fire fighting equipment is serviced annually and the home has a plan in place in the event of a fire. Fire drills are held regularly. Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 Page 14 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 3 Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 Page 15 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 OP26 Regulation 23(2)(c) Requirement The Registered Manager must ensure that the kitchen is returned to an acceptable level of cleanliness. Timescale for action 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 Page 16 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Birchville Court Nursing Home DS0000019293.V282073.R01.S.doc Version 5.1 Page 17 - 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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