Inspection on 18/06/07 for Birchwood

This inspection was carried out on 18th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Birchwood 28/02/06

Birchwood 19/10/05

Birchwood 16/03/05

Birchwood 14/09/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Birchwood Fullers Close Chesham Bucks HP5 1DP Lead Inspector Chris Woolf Unannounced Inspection 18th June 2007 09:05 Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 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 Birchwood DS0000061743.V339387.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 Adults 18-65. 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. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchwood Address Fullers Close Chesham Bucks HP5 1DP 01494 794112 01494 794115 john.inker@scope.org.uk 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) SCOPE Mr Jon Inker Care Home 15 Category(ies) of Learning disability (2), Physical disability (13) registration, with number of places Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: Birchwood is situated on the outskirts of Chesham, with a variety of shops, a theatre, various restaurants, good transport links, and other local amenities nearby. The home is run by the organisation SCOPE, and has been purpose built to provide accommodation for 15 service users with physical or learning disabilities. It is fitted with the latest in disability aids. All service users rooms are on the ground floor, and staff accommodation, office and storage space are situated on the first floor. There are thirteen single rooms with en-suite shower and/or bath, and one shared apartment with lounge, bedroom, kitchen and bathroom. Extensive tracking hoist systems are present in all rooms. A covered car parking space is adjacent to the apartment. The home is divided into three self-contained units. The homes staff team includes care staff, physiotherapists, activities organisers and speech and language therapists. Access to allied healthcare professionals is possible through direct contact or referral by the service users general practitioner. The current fees for the service at the time of the visit range from £965 to £2076 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is jon.inker@scope.org.uk Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information in this report has been obtained from a pre-inspection questionnaire completed by the manager; comment cards received from 11 service users, 6 visitors, and 2 General Practitioners; and an inspection site visit to the home of just under 7 hours. The inspection site visit included a tour of the building; talking with service users, staff, and the manager; various observations; and inspection of a selection of records kept by the home. What the service does well: What has improved since the last inspection? Staffing and care support levels have increased following a couple of effective advertising pushes. New transport has been approved by Scope and is now on order. 1 x 5 seater vehicle is due Summer 2007, and 1 x 5 seater vehicle is due Spring 2008. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 6 Activities have increased and now include Rebound Therapy, Citizenship, new Adult Learning classes in Drama and Photography, and swimming. Therapies have increased and the home now has a visiting Indian Head Massage and Reflexology service. There are also 2 Physiotherapists and 3 Speech and Language Therapists coming into the service regularly. Communication - A new technical support partnership has been formed with Amersham Hospital Speech and Language Therapy department to aid Communication by enhancing the identification of lightwriter faults and organising swifter repairs A new Speech and Language Therapy survey has been introduced every 6 months to gauge need and effectiveness for this service. A new Plasma screen TV has been purchased for Chess unit. A new laptop and projector to allow greater group participation plus a range of educational; and fun games for the day service have been purchased. A new system of care Profiling has been introduced to more effectively assess need to cost. A new client support hospitalisation protocol has been developed. A new partnership has been formed with an outside company to support staff on NVQ training and assessment. 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. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients can be confident that their needs will be assessed and that they will be offered a trial visit prior to admission to the home. EVIDENCE: The Deputy Manager, together with a Care Manager from the learning disability team, carry out a joint, comprehensive and holistic needs assessment for all prospective clients. This takes place in their current home. The needs assessment includes Personal Care, continence, transfers, behaviour, meals and support needed, medications, therapy, things they like to do, daily living, equipment support, and health care. These are all taken into consideration in the newly introduced care profiling which more effectively assesses need to cost and helps to set the level for the fees from Social Services, as well as being used to form the basis of a care plan. A local authority assessment report in the form of a pen picture is also received for all clients. The home is able to demonstrate their ability to meet the needs of prospective clients. Specialist services offered include physiotherapy, and speech and language therapy. Staff are trained to help clients with their communication Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 9 needs and the home has formed a new technical support partnership with Amersham Hospital SLT to enhance the identification of lightwriter faults and swifter repairs. Independent advocacy schemes are available to help prospective clients during the process of choosing a home. The current age range in the home varies from 28 to 74. The older clients have been with SCOPE for many years transferring to Birchwood from their previous home when it was first built. The manager is amending the home’s Statement of Purpose to reflect the fact that, although they will only admit clients in the 18-65 age group, should any client go over that age they may remain at Birchwood for as long as the home can meet their needs. All prospective service users are offered trial visits. Initially clients’ parents visit the home for a tour and a chat, then the client comes in for a day, and if they are happy a 2-week stay follows this. The first three months of occupation is then classed as a ‘settling in’ period. The majority of clients moved to Birchwood when it was built. A member of staff commented, “the clients are much happier since they moved here”. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients are involved in drawing up a holistic plan of care; they are encouraged to take decisions in all aspects of their lives; and are supported in taking responsible risks. EVIDENCE: A comprehensive and holistic service user plan is produced for every client. The care plans include details of individual likes and dislikes, communication needs, health care appointments, personal goals, individual work record, eating and drinking information, wheelchair information, risk assessments, pressure information, key-worker notes, charts, fall risks, mental healthcare, behavioural and family links, meeting needs matrix, and contents of room. All care plans are regularly reviewed. The information in the care plans gives clear instructions to staff on how clients like things done for them and how much they can do for themselves Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 11 and this information is written with the involvement of the client and their family or advocate. Each client has a key worker who they can relate to, and who can communicate with them. Clients are encouraged to make decisions about all aspects of their lives and are provided with communication aids to support them in making and putting forward their decisions. Staff confirmed that choices include what to eat, whether to go to the day centre, what time to get up and go to bed, what to wear, who to mix with, the colour scheme for their rooms, where and if they wish to go on holiday. There was a recent sandwich tasting session in one of the units to encourage the clients to try different foods. When a vacancy came up in one of the units one client recently requested to move units and commented ‘I have recently moved units and I am much happier than I was before’. All clients have the private option to take up an advocate to help them in decision-making, using ‘Peoples voices’. All clients or their families or advocates deal with their own finances. Every client has his or her own personal bank account and the manager is not a signatory on any client account. Clients visit the banks in Chesham which all now have ramped access. Clients are supported to take responsible risks. Individual risks and strategies for minimising the hazards are identified and are recorded in the care plan. The home has policies and procedures in place for risk assessment and management, and for missing persons. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients have access to appropriate activities and community access; they are encouraged to maintain links with their family and friends and they have meals of their own choice. EVIDENCE: None of the existing clients go out to work but they do attend various college courses including Art & Craft, Drama, Crafts for Christmas, Citizenship, Photography, and Enjoying music. Clients are supported to take part in community activities. Most clients go to the SCOPE day centre 2-3 times a week, and the day centre organises trips out. A client said, “I go to the day centre now and again”. Clients like to go shopping and are taken into Chesham by staff, either by wheelchair or in the bus. This enables them to do banking, and to visit the Post Office or Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 13 supermarket. For other shopping they go further afield, usually to Hemel Hempstead. Some of the clients have expressed an interest, and the home are currently looking into visiting Green Park, a specialist centre with adventure based activities such as abseiling down a wall in a wheelchair, blank wall climbing, and canoeing. The home currently organises trips out for swimming, rebound therapy, sensory room, and for adult learning classes. The home currently does not have many volunteers for drivers, but are running adverts at present in order to increase the numbers. One staff member commented, “My husband has been CRB checked to be a volunteer driver”. Several of the clients go out to local churches. Client comment cards included, ‘I would like to go out more often and meet other people. I don’t go to the day centre because it’s the same people I live with’, ‘I have recently taken part in a production of Goldilocks & the 3 bears’, ‘I attend meetings at Market Road’. Visitors comment cards expressed concern about insufficient transport being available. Comments included, ‘xxx is asked if she wants to participate and is given the choice and is informed of new education schemes open to her. At the moment there are outside education classes she can attend every weekday BUT sometimes she cannot go to them because the transport they have is only able to take 3 people and she has to take turns. Transport is the difficulty!!’ and ‘Today I was informed of the new and many activities available for xxx which she has attended and loves BUT transport is not good. A bus has been promised but so far has not materialised - they have been waiting, I believe a year so far’. New transport has now been approved and budgeted for by SCOPE. A 5 seater vehicle is on order and due in Summer 2007 and a further 5 seater vehicle is due to be delivered in Spring 2008. A variety of leisure activities are organised in the home. There is Bobbin lace every week and lifestyle sessions with professional tutors for arts & crafts, drama, English, and maths for the terrified. The home is currently planning a photography course. The recent purchase of a laptop and projector with games and interactive programmes for the clients has been welcomed. Some of the clients find that there is less to do at the weekend. There are no activities arranged by the home as this is a time that families visit, and some clients go out. The funding received from Social Services does not allow for weekend activities, but if additional funding were made available activities would be arranged. Clients are encouraged to maintain links and friendships both inside and outside of the home. One comment card included the statement, ‘I have made friends with some people from the local church and drama group and they take me out a lot’. A client said, “My cousin is getting married in July, when she was a baby I held her in my arms”. The manager confirmed that the home would be assisting this client to attend the wedding. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 14 Daily routines in the home are flexible to meet the needs of the clients. Staff always knock and wait to be invited in before entering clients bedrooms. Interactions between staff and clients are relaxed and friendly. Some clients are able to do small household chores such as tidying of their own bedrooms. Meals at the home are of the clients choosing. Each unit has their own kitchen and decide on their own menu for the week. On the day of the inspection site visit 3 service users in one unit were observed enjoying lunch and each had a different meal of their own choosing. A service user said, “we are allowed to have what we like. The carers jot down what we like and get it then cook it for us. I like pork pie, veggies and mashed potatoes. I like cake, Battenberg is best”. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Clients can be confident that their health care needs will be met by the home supported by a multi-disciplinary health care team. EVIDENCE: Personal care is carried out in accordance with clearly written protocols agreed with the clients and recorded in their care plans. Staff encourage clients to maintain their own independence and to make their own decisions as far as they are able. Times for getting up, going to bed, baths etc. are flexible. The home is well equipped with aids. Each bedroom and en-suite bathroom has a hoist tracking system and there are individual slings for the hoist for each client. Rooms and corridors have been designed to allow room for the movement of wheelchairs and there is a wheelchair charging room in each of the units. A new standing frame has recently been purchased and is being used with the clients by the physiotherapists. Clients have good access to communication aids such as lightwriters. A new technical support partnership has been agreed with Amersham Hospital speech and language therapy Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 16 department to enhance the identification of lightwriter faults and to facilitate swifter repairs. Healthcare needs of the clients are being met by the staff of the home together with a multidisciplinary team of health care professionals including doctors, physiotherapists, speech and language therapists, chiropodist, Dietician, Psychologist, Dentist - either clients go to the surgery or he will visit the home, Opticians - some have a visiting optician and others go to the High Street practices. Clients’ health is monitored and annual health checks are organised. A new speech and language therapy survey has been introduced every 6 months to gauge the need and effectiveness of this service. All visits to or by health professionals are recorded in the clients care plan. The home has recently introduced an ‘Indian Head Massage and Reflexology’ service. They also now have 2 physiotherapists and 3 speech and language therapists coming into the service on a regular basis. A visitor comment card included, ‘In the case of my daughter they are most mindful of her ability to swallow food and the difficulty to digest food’. A new client support hospitalisation protocol has been introduced since the last inspection. In June 2007 the home was presented with the South Bucks & Beds News, Certificate of Merit in the Carers and Caring Home Awards 2007/8. Medication policies and practices in the home are good. The pharmacist from Boots inspects twice a year. Recording of receipt, administration and disposal of medication is sufficient to allow an audit trail. Medication storage is satisfactory with each person having a separate box and external and internal medication being stored separately. The home has policies and protocols for homely remedies. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients know that their concerns and complaints will be listened to and acted upon and that they will be protected from abuse. EVIDENCE: The home has a clear and accessible complaints procedure and a copy is on display. Service user and relative comment cards confirmed they knew how to make a complaint. There have been 2 complaints since the last inspection, and one of these was partially upheld. Both complaints were satisfactorily investigated and outcomes were recorded. Clients know they can talk to the manager with their concerns whenever they want. Clients are protected from abuse. The home has robust policies for Adult Protection and Whistleblowing. All staff have adult protection training and confirmed that they would know what to do if they suspected that abuse was taking place. A satisfactory check of the Protection of Vulnerable Adults register is obtained prior to appointment of any new member of staff. The home’s policies and procedures regarding the protection of service users monies and valuables are sound. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Clients live in a clean, well-maintained home that has been designed to meet their needs. EVIDENCE: The home has been purpose built and is very suitable for its use with wide corridors, and spacious rooms. It is divided into 3 separate units each named after rivers by the clients. Chess has 5 single bedrooms and 1 apartment for 2 clients to share. Isis has 5 single bedrooms. Avon has 3 single bedrooms. Avon and Isis are joined with a link room, and Chess is completely separate. The link (or Winter garden) between Isis and Avon is very light and airy and is used for the bobbin lace on a Friday, for physiotherapy, and for meetings. Chess is the only unit with first floor accommodation and this comprises a sleep in room, staff bathroom, staff rest room/kitchenette, training room which Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 19 is also used by the speech and language therapists for paper work, an office, ample storage space. There is ample storage in the home generally, including a room in each unit for the charging of wheelchairs. There is under floor heating throughout the home avoiding the need for radiators. Towel rails are all guaranteed low surface temperature. The entrance has automatic doors. All doors to service users bedrooms are on magnetic holders. All rooms are individually thermostatically controlled, and all taps are fitted with thermostatically controlled valves. Each of the units has its own lounge with ample wheelchair turning space; an open plan kitchenette with walk in pantry. SCOPE has provided televisions for the lounges, and a new plasma screen T.V. has been fitted in Chess since the last inspection. Although all of the kitchens are the same design they have different colours, and very different foods in the fridge/larder to suit the needs and choices of the clients in the individual unit. Kitchens include cooker, microwave, dishwasher, fridge freezer, hand wash sink, blender, and other equipment. Each unit also has its own laundry with industrial washing machine. The apartment has a lounge, kitchen, double bedroom, and a bathroom. Each bedroom has its own large en-suite bathrooms. Bedrooms and bathrooms are fitted with tracking systems for hoists, and all clients have their individual slings for these. All bedrooms are highly personalised. When the home was built an interior designer worked with clients and families to choose the colour scheme, curtains and furniture to meet their individual needs. All rooms have posture beds with ripple mattresses. There is an accessible nurse call system in all rooms. Clients families have provided them with televisions for their own rooms. A client commented, “I was in PMC for 49 years, they are bigger rooms here and we have our own toilet and bathroom. Its much better, we had to share the toilet and bath in PMC”. The patio areas outside of clients’ bedrooms have been personalised. One client was growing strawberries and tomatoes on her patio area, and several other clients had ornaments. There is also a patio at the rear of the Winter Garden link that is used for Bar-b-ques and events such as the strawberry tea. At the front of the home there is a grassed area, and there are open views across the countryside from many of the rooms. The home is clean and odour free throughout. Infection control procedures in the home are good. Staff have not yet received Infection Control training but this is scheduled. The home is the 2006 winner of the George Plucknett Award from the National Home Improvement Council for an outstanding level of achievement. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients are cared for by a team of staff who are trained to meet their needs. EVIDENCE: Staff who are employed at the home receive training to meet the needs of the clients. Agency staff receive the same induction and training as the regular carers for the home. Currently there are over 50 of care staff with NVQ level 2 or above and a further 8 are about to start this training. The home’s administrator has also achieved NVQ level 2 in administration. The home has recently formed a new partnership with a company to support staff on NVQ training and assessment. Staff who administer medication receive medication training. Currently there are some who are part way through completing the Boots foundation medication course and the deputy manager has assessed the competency of these staff. Specialist physiotherapists and speech and language therapists are brought into the home to meet the more specialist needs of the clients. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 21 Some visitor comment cards expressed concerns about the levels of staffing including, ‘… a shortage of staff means this can’t happen sometimes’, They could improve by ‘maintaining full time regular well trained staff’, and ‘at weekends there is always a shortage of staff’. Since receipt of these comment cards (March 07), the home has had a couple of effective advertising pushes and staffing is now at agreed care support levels. The home does use agency staff from time to time but always tries to get the same people to ensure continuity of care for the clients. Some of the care staff also come into the home to do things with the clients in their own time. A member of staff said, “I have come in on days off to go with them, its such good fun”. Client comment cards included, ‘We get all sorts of staff but the majority are very nice’, and ‘some staff are nicer than others’. The home operates a robust recruitment process. No new member of staff is employed until 2 satisfactory references have been received, a satisfactory check has been made against the Protection of Vulnerable Adults register, and an enhanced disclosure has been submitted to the Criminal Records Bureau. Criminal Records Bureau checks are also carried out for all volunteers. Currently staff files do not fully comply with the revised Schedule 2 of the Care Homes Regulations, as application forms do not ask for a full employment history. A recommendation has been added regarding this. Each member of staff has a training and development profile. All new staff have induction training to Skills for Care specifications. Staff have all been trained in the mandatory subjects, apart from Infection Control, which is scheduled. Staff are also trained in Adult Protection. Training for all staff in Equality and Diversity is being arranged by SCOPE starting in July 07. The home has recently had a visit from ‘Skills for Care’ and are now undertaking an audit of all training. Staff receive supervision and support on a regular basis and the manager and deputy are also available to talk to staff on a daily basis. General comments from staff included, “I love it here”, “this is the happiest I have been”, and “I thoroughly enjoy being here, I will be very sad to go but I am moving.” Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the clients. The health, safety and welfare of clients and staff are protected EVIDENCE: The Registered Manager has achieved an NVQ Level 4 in Care, a Registered Managers Award, and NVQ Level 5 in Operational Management. He is competent, experienced, and qualified to run the home. A Deputy Manager, an administrator, team leaders and care and domestic staff support him in his role. The deputy manager has achieved NVQ 4 in Care. All staff spoken to confirm that the manager and the senior management support them. Two staff said, “absolutely”. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 23 The ethos of the home is open and welcoming and the manager operates an ‘open door’ policy. A client commented, “The manager is the best. He is fair and he is interested”. Staff comments included, “It’s very nice and relaxed here, Jon is very good”, “The manager and deputy are terrific, always there and always willing to listen”, and “I have never seen Jon or the administrator say no to a client”. The home has developed good quality assurance strategies. Questionnaires are circulated to service users and visiting professionals 6 monthly. There are regular audits of Quality of Care, Care Plans, Fire, Water temperatures, and Legionella. The meeting needs matrix is reviewed within 6 months. All policies and procedures are reviewed annually. Regulation 26 visits are now unannounced and have recently been changed to Peer visits. The home has a clients group Birchwood voice, which is independently chaired by an advocate, and meets monthly. The manager is invited in at the end of the meeting to discuss any issues that have come up. Staff meetings are held monthly. Team leader meetings take place fortnightly. The manager has a 1:1 monthly with his line manager. The manager is currently writing a concept paper to move to more independence of clients. The manager promotes the health, safety and welfare of clients and staff. Mandatory training is given to all staff. All fire, equipment and safety checks viewed were up to date. Accident records are in order and a monthly accidents analysis and summary is produced. Risk assessments are produced for all identified hazards. Birchwood DS0000061743.V339387.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 Adults 18-65 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 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 3 26 4 27 4 28 4 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 4 3 X X 3 X Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 YA34 Good Practice Recommendations Staff files should be updated to comply with the revised Schedule 2 of the Care Homes Regulations, particularly in respect of gaining a full employment history for all staff. Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Birchwood DS0000061743.V339387.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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