Inspection on 18/09/07 for Birchwood

This inspection was carried out on 18th September 2007.

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

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

Other inspections for this house

Birchwood 13/09/08

Birchwood 14/11/06

Birchwood 22/02/06

Birchwood 07/05/05

Birchwood 29/12/04

Birchwood 05/10/04

Birchwood 03/03/04

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

CARE HOMES FOR OLDER PEOPLE Birchwood Adult Community Care Beam Street Barton Hill Bristol BS5 9QR Lead Inspector Sandra Jones Key Unannounced Inspection 09:30 18 & 19 September 2007 th th 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 Birchwood DS0000036679.V346189.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. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchwood Address Adult Community Care Beam Street Barton Hill Bristol BS5 9QR 0117 9712266 NONE 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) Bristol City Council Miss Debra Jane Clifford Care Home 30 Category(ies) of Dementia (30), Dementia - over 65 years of age registration, with number (30) of places Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 30 persons aged 60 years and over. Date of last inspection 14th November 2006 Brief Description of the Service: Birchwood is a large purpose built residential home operated by Bristol City Council. It is registered by The Commission for Social Care Inspection to provide personal care to 30 persons aged sixty five years and over with dementia. There is a condition to the registration which allows the home to accommodate 30 persons aged sixty years and over. All rooms are single and have been tastefully furnished to meet the individual needs of the occupants. The home is alarmed and secured, with a door entry system. There are spacious bright lounges for service users and their relatives to relax in and the dining room is well proportioned with ample space for moving around. There is an attractive courtyard with shrubs, plants and sitting area. Within the home there are aids and adaptations to aid mobility and this also includes hoists in the bathroom. Birchwood is situated in the south of Bristol and is on a major bus route. Fees are £584.99 week and extra charges are made for chiropody, hairdressing etc. Currently this information is initially only provided verbally prior to admission. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was conducted unannounced over two days in September 2007 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. The Short Observational Framework for Inspection (SOFI) was used to capture the experiences of people that use the service. Two hours was spent observing the care being given to a group of individual. All observations were followed up by discussions with staff, manager and examination of the records. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from the staff. “Have your say” surveys were sent to relatives, health care professional and staff. Feedback was received at the Commission from two relatives and two staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the AQAA (Annual Quality Assurance Assessment) and notified incidences in the home, (Regulation 37’s). This information was used to plan the inspection visit. There are twenty-seven people are currently living at the home and four were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. What the service does well: Members of staff were observed giving individuals choices and allowing the person to make decisions about their meals, the level of assistance and where Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 6 to go. Individuals were positive whenever staff engaged with them and staff addressed the individual correctly. “Have your Say” survey from staff and relative state that caring for individuals needs is what the service does well. It is evident that there is a maintenance programme and the property is decorated to an adequate standard. Complaints are taken seriously, investigated and the organisation seeks to resolve complaints to a satisfactory outcome. What has improved since the last inspection? What they could do better: There are a number of requirements arising from this site visit and two that are outstanding from the previous inspection visit. Failure to meet legislation will result in enforcement action. Requirements arising from this inspection are based on making information accessible to the people for whom the service is intended. The Statement of Purpose must be reviewed to make clear the range of needs that can or cannot be met at the home and to include the admission procedure. Care planning must be further developed by using a person centred approach to meeting needs. Individuals likes, dislikes and preferred routines must be integrated within the care plans and all aspects of the individuals life must form part of the process and must include communication and social care needs. Risk assessments that include strategies for managing aggressive and violent behaviours that addresses safeguarding from abuse must be included in care plans for people that may exhibit aggressive and violent behaviours. In terms of privacy and dignity, members of staff must be mindful that individuals at the home have rights, which include privacy and dignity. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 7 Individuals at the home must be have their rights to privacy and dignity respected at all times. The manager must ensure that members of staff use correct manual handling techniques to assist individuals with mobility needs. Training that is specific to the needs of the people at the home must be provided to ensure that staff have the skills and qualifications to meet the changing needs of the people at the home. 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 DS0000036679.V346189.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the service is provided to enable the individuals representative to make choices about living at the home. The Statement of Purpose must be reviewed to make clear the admission procedure and the range of needs that can be met at the home. Consideration must be given to accessible formats so that individuals can be part of the decision making about living at the home. EVIDENCE: Birchwood offers accommodation for up to thirty people with dementia and at the time of the site visit, twenty-seven people were accommodated. As well as long-term care, the home accepts emergency admissions. The home will offer accommodation to individuals aged sixty-five years and over. The home has a Statement of Purpose in place, which includes the Admission procedure and states that individual must have a diagnosis of dementia from a psychoBirchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 10 geriatrician before they can be considered for admission at the home. The Statement of Purpose must be reviewed to make clear the age range, the criteria for admission and the range of needs that can or cannot be met at the home. One “Have your say” survey was received from a relative and it states that sufficient information was received to enable individuals to make decisions about living at the home. The manager said that accessible formats for people with dementia have not been considered. Consideration must be given to the formats used so that individuals can be part of the decision-making. The case file of the most recently admitted individual was examined and a needs assessment from the social worker was available. The manager said that a home’s care plan is not formulated for the first four weeks of admission. Home’s care plans are devised after the four-week review and in the meantime running reports are used to detail the person’s likes, dislikes and preferred routines. Once the four-week review takes place the staff will sit and develop the care plan from information gathered through observation and reports of the person. Members of staff need to be careful about the language used to describe preferred routines because judgements about behaviours can be made when subjective terminology is used. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care planning systems must be more effective so that individuals can benefit from receiving individualised and consistent service. Individuals can expect sensitive and prompt support for their personal and health care needs. Medication systems must be safer for the people at the home. Members of staff must be mindful of individuals right to dignity and privacy. EVIDENCE: Care plans list the individuals needs and overall guide the staff on the actions to be taken. Care plans must be more person centred in the way the actions are to be taken by the staff to meet the assessed need. In using Person– centred care for people the key elements that value people with dementia are used and include treating the person as an individual, taking the perspective of the person with dementia and providing supportive social psychology. The manager recognised that more information must be added to the care plans to give staff a better overview of the person. Care plans must also ensure that all aspects of needs are included and must specify the way the person dementia Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 12 manifests itself, communication and social care needs. Two members of staff on duty giving feedback about the care planning process said that care plans are generally formulated by senior staff, which are then discussed with caring staff. Keyworkers monitor care plans monthly and recorded are the outcomes, reviews and the action taken. Staff confirmed that keyworking is part of their caring role at the home and said that they are responsible for undertaking 1:1’s, arranging shopping trips and the individuals appearance. Where activities that involve an element of risk are identified, risk assessments are completed. One person has pressure sores and the district nurse visits regularly to dress the pressure areas. Equipment was purchased for three individuals that have a history of pressure sores to prevent any reoccurrences. In terms of continence issues, the Continence Advisor visits the home to provide training for the staff and district nurses assess the individuals needs for continence aids and equipment. Multidisciplinary visits from health care professional are recorded separately from the care plan and the dates of the appointment and, outcome of visits and the signature of the staff is included within the record of the visits. Medications are administered through a monitored dosage system by the staff and records of administration show that staff sign the records after administering medications. Medications held within the cabinet were checked against the records and medications cross-referenced with the records. A record of medications no longer required are maintained which is signed by the pharmacist to indicate receipt of the medication for disposal. The deputy manager said that homely remedies are not administered when required from a stock supply and, GP’s prescribe analgesics for people that need pain relief. It was noted that the home has large quantities of stock medication and a visit from the Pharmacy Inspector has been requested. The deputy manager was consulted about the way staff assess that individuals are in pain and need analgesics. The deputy manager said that body language and non-verbal methods of communications are also used to determine if a person is in pain and requires pain relief. During the Short Observational Framework for Inspection (SOFI), a member of staff was observed undertaking personal care in a communal area. Members of staff were also observed using poor manual handling techniques to assist individuals with standing. The Privacy and Dignity policy is included in the Statement of Purpose and the approach is established through the training provided to staff, management of the home, facilities available and routines followed. Members of staff said that Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 13 they maintain individuals right to privacy and dignity by conducting personal care in private, knocking on bedroom doors before entering and seeking the individuals preferences about the manner in which personal care is conducted. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Programmes of activities have been developed and, support systems in place must be further developed for individuals to lead active and interesting lifestyles. Meals are attractively presented and smell appetising. EVIDENCE: There is an activity board that lists in-house activities, visitors to the home and events. In-house activities generally take place in the afternoon and include choir and aromatherapy. The manager said that keytime is allocated to staff with specific individuals at the home and there is an expectation that members of staff record activities undertaking during keytime. It is evident from the record of keytime that staff spend time with a group of individuals watching films discussing past times while completing other tasks. The manager said that keytime is in addition to in-house activities provided by the staff in the afternoon. The records of keytime and activities does not support the comments made by the manager. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 15 The Short Observational Framework for Inspection (SOFI) was used to capture the experiences for people who use the service. During this site visit a significant period of time was spend in the foyer observing individuals and their level of engagement with their surrounding, staff and visitors to the home. It is evident from the observation of the individuals at the home that overall staff integrated well with the individuals, individuals were correctly addressed and choices were provided particularly around meal times. Individuals responded well when staff engaged with them. However, staff only engaged with individuals whenever tasks were undertaken. One person was handed a newspaper by the staff and the person put the paper beside them and staff made no attempt to assist the person with reading the newspaper. A member of staff then conducted personal care in the lounge, the staff was called away and when the staff member returned, the person was asked to go into another room. This person was then assisted to stand and poor lifting techniques were used, the person said to the staff “It hurts”. When another member of staff supported this person to stand, the member of staff waited for the person to stand before giving support and this individual did not say anything about their arm. At lunchtime, members of staff were observed seeking permission from certain individuals to use protective clothing. Visual choices were given to individuals with communication needs and staff sat beside individuals that needed support with eating their meals. Members of staff were observed coaxing individuals to eat their meals and alternatives were offered where choices were refused. However, members of staff did not appear to notice that one person needed assistance from staff with personal care. Members of staff could have handed a tissue for the person to undertake their own personal care, instead the dignity of this person was not observed. There is a four-week rolling menu and shows that the main meal is at lunchtime, a lighter meal is served at teatime and supper consists of sandwiches, hot drinks and biscuits. The cook said that the manager devises the menus and the staff inform catering staff about the individuals likes and dislikes. There is a wide range of fresh, dried and frozen food, which reflect the menus in place. The Statement of Purpose stated the home’s visiting arrangements which confirms that visitors are welcome at the home at all times. During the site visit visitors were observed entering the home and undertaking their visits in their relative’s bedroom and in communal areas. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals can expect their concerns to be listened to and to be protected from abuse. Consideration must be given to way individuals are enabled to make complaints consideration must be given to the formats in place. Care plans for people that exhibit aggressive and violent behaviour must be clear about the triggers and actions that must be taken by the staff to diffuse and divert incidents. EVIDENCE: Two “Have your say” surveys from relatives state that they always know whom to approach with complaints and they always respond appropriately. Surveys from two staff state that they know what to do when individuals at the home, their relatives or advocates make complaints to them. During the site visit two staff were consulted about the way people with dementia are enabled to make complaints. Members of staff said that speaking to individuals and behaviour changes are triggers that something is wrong. While Complaints leaflets are in the foyer of the property, they are not written in formats that will enable the person living at the home to make a complaint. The manager said that the Complaints procedure is discussed during review meetings and initial assessments and relatives mainly advocate on behalf of the person living at the home. It was additionally stated that every effort is made to deal with complaints at the lowest possible level. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 17 Two complaints were received at the home since the last inspection and were investigated by the responsible individuals. One complaint was from a relative and an outcome to the complaint was reached and the other is from a member of the public and is under investigation by the external manager. The manager said that there were no outstanding Safeguarding Adults referrals and it the aim for all staff to attend the training. Two members of staff giving feedback explained that their responsibility for safeguarding adults from abuse is to raise concerns and alert the manager of allegations of abuse. Aggression and violence was discussed with the manager and it was stated that eleven individuals at time may exhibit aggressive and violent behaviours. The manager said that the In-Reach team are used for advice to the staff and to set behaviour strategies for the individual. Care plans must be clearer about the triggers and actions to be taken to by the staff including any Safeguarding Adults measures in place. Regarding training, the manager said that because of the number of individuals accommodated that at times exhibit aggressive and violent behaviour, Violence and Aggression training was being considered. Initially the manager and deputy manager will be undertaking Challenging Behaviour training and the information will then be cascaded to staff. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The individuals at the home benefit from living in a comfortable environment. The care home is clean and free from unpleasant smells. EVIDENCE: Birchwood is a large purpose built care home for up to thirty people with dementia in the sixty-five years and over age range. It is close to shops, amenities and a major bust route. The property is arranged over two floors with shared space and bedrooms on both floors. Access to the first floor is by a lift so that less mobile individuals can be assisted to move around the home easily. There is a large dining room on the ground floor and the four lounges are themed which include a reminiscence lounge to stimulate the individuals Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 19 memory. Individuals also use the entrance hallway as a social space and seating is available. Bedrooms are single and have the name of the person, their photograph and name of the keyworker so that individuals can find their own bedrooms. Bedrooms have a combination of the home’s furniture and personal belongings and reflect the individuals personality. There are toilets and bathrooms of both floors and toilet doors are painted green with a picture of the toilet to support individuals to find the toilet. There are two doors that lead into the courtyard garden and the manager said that the doors are unlocked each morning so that individuals can go into the garden without having to ask. Keypads are used in sluices, kitchen and admission area which are not used by the individuals at the home. The laundry room has two washing machines, with sluicing facilities and separate sluicing area. It is evident from the tour of the premises that there is a programme of refurbishment at the home. One relative said through the “Have your say” survey that the home is usually fresh and clean. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A competent staff team who are well supervised support individuals. Training must be improved to ensure the staff are skilled and qualified to meet the changing needs of the people at the home EVIDENCE: The manager said that currently there are two part time care assistants and one-night care assistant vacancies. Staffing levels at weekends differ from weekdays, during the week five care assistants are rostered in the morning, four in the afternoons and four in the evenings. At weekends staffing levels are reduced, there are four care assistants in the morning, three in the afternoon and evening. The manager said that recently there was a shortterm increase in the staffing levels at night to meet the changing needs of one person. It is unclear why staffing levels change during the weekends because the number of people accommodated and needs of the individuals remain the same during the week. A relative stated through the “Have your say” service user survey that the staff are always available when they are needed. Two “Have your Say” surveys were received from the staff and one person said that sometimes there was enough staff and the other said it was usual for enough staff to be on duty, Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 21 The manager confirmed that agency staff are used at the home and said that the aim is to use the same staff so that individuals at the home see the same faces for continuity of care. It was also stated that where possible shifts are arranged that agency staff work with permanent staff. The manager said that yearly Personal Development Plans are used to identify the staff’s training needs, which include statutory training. Statutory training includes of Manual Handling, First Aid (for night and officer staff), Basic Food Hygiene (for cooks and kitchen staff), Safeguarding Adults, Fire and Equalities. A four-day Dementia Workshop was provided in 2003 for all the staff to raise their awareness and insight into the needs of people with dementia. It is evident from the training records that refresher training in dementia must be provided to the staff at the home to maintain their skills. Two “Have your say” surveys were received from staff at the home and states that training that keeps their knowledge and skills up to date with current good practice, is provided. Two members of staff were consulted about access to training and it was confirmed that training is always offered. Additionally, it was stated that they had achieved an NVQ level 2 qualifications. Bristol City Council Adult Community Care personnel department currently holds staff files centrally. A separate inspection to the personnel department will take place to assess the recruitment procedure. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals can expect to live in a safe environment and to be re-assured that standards will be the subject of ongoing monitoring. EVIDENCE: The manager was consulted about the type of leadership and systems in place to maintain and develop the standards of care at the home. The manager said that courses such as the Team Leadership Foundation course and NVQ level 4 have assisted in looking at ways to improve staff performance through support and open leadership. It was further stated that improving the individuals life at the home is at the centre and through regular officer meetings, with external managers attending for support, the way forward is discussed. Staff meetings will then follow which are alternated to reach all the staff working at Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 23 the home. Consultation through handovers, staff suggestions are sought and where individuals at the home benefit suggestions are implemented. The external manager visits the home monthly to fulfil the requirements of Regulation 26 and completes a report on the conduct of the home. An external Quality Assurance company is used to seek feedback from relatives and professional agencies about the quality of care provided by the home. The manager said that questionnaires are sent directly from the consultancy office to relatives, health care professionals and other visitors and the home receives the report. Critical points raised through the report are discussed at officer meetings and filtered through to staff meetings. Feedback received from other sources including individual review meetings which is actioned as issues occur. The arrangement for payment of fees was discussed with the manager. It was stated that there is a standard rate of £603.00 per week for accommodation in Local Authority provision for people with dementia. Facilities for the safekeeping of cash of cash exists and cash is currently held on behalf of the people at the home. Records of each transaction is kept, with the signature of the member of staff and receipts to further evidence the purchases made on behalf of the person. The sample check of cash held in safekeeping crossreferenced with the records, which show that records are up to date and correctly maintained. The home maintains reports of accidents to individuals and staff that occurred at the home. The manager ensures that the home complies with associated legislation to ensure individuals live in a safe environment. A competent contractor undertakes annual checks of the passenger lift, manual handling lifting equipment and bath facilities. Gas central heating and portable electrical equipment is also checked annually by a competent person. The manager said that fire risk assessments will be reviewed and the format changed. It is specified within the risk assessments that regular checks of fire alarm systems, fire extinguishers and emergency lighting equipment and the provision of training and fire drills for staff will be provided a safe environment for the people at the home. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 2 2 2 2 2 2 3 STAFFING Standard No Score 27 2 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Birchwood DS0000036679.V346189.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. 1. Standard OP12 Regulation 16(6) Requirement Arrangements must be made to ensure that all residents are provided with meaningful key working time (one to one on a regular basis each week. (Partially met) Timescale for action 15/12/07 2. OP27 18(1)(a) (b)(c) A review of the staffing team numbers must be completed. The staff vacancies must be addressed in this review and a plan sent to the CSCI demonstrating how the vacancies are going to be filled and what arrangements are in plan to ensure that residents receive consistent care from trained competent staff at all times. (Repeated 18/09/07) 15/11/07 3 OP1 6 The Statement of Purpose must be reviewed to a) include the admission procedure, b) to describe the range of needs that can or cannot be met at the home, c) consider the format for DS0000036679.V346189.R01.S.doc 28/02/08 Birchwood Version 5.2 Page 26 4 OP7 12(3) 5 OP7 15 (1) 6 7 OP10 OP10 12 (4) (a) 12 (4) (a) 8 OP8 13(5) 9 10 OP12 OP16 16(2)(n) 22(2) 11 OP18 12(4) (b) 12 OP30 18 (1) (a) people for whom the service is intended. A person-centred approach must be used to meet the individuals needs by including the persons likes, dislikes and preferred routines into their care plans. Care plans must include all aspects of the individuals life including the communication and social care needs. The terminology used to describe behaviours must be factual and not subjective The individuals rights to privacy and dignity must be observed in all aspects of their lives by the staff at the home Members of staff must use correct lifting techniques to support people with mobility needs Individuals at the home must experience meaningful activities. The Complaints procedure must be in a format that can be understood by the people for whom it’s intended. Care plans must include strategies for people that exhibit aggressive and violent behaviour in order to guide staff on the actions to be taken to diffuse incidents. Training that meets the needs of the people living at the home must be provided 30/12/07 30/12/07 30/11/07 30/11/07 30/11/07 30/12/07 28/02/08 28/02/08 30/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 27 No. 1. Refer to Standard OP36 Good Practice Recommendations Supervision records must be available for inspection Birchwood DS0000036679.V346189.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000036679.V346189.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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