Inspection on 04/05/06 for Birchwood

This inspection was carried out on 4th May 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 found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birchwood 04/01/06

Birchwood 29/06/05

Birchwood 06/10/04

Birchwood 19/05/04

Birchwood 02/02/04

Similar services:

Littledale Hall Therapeutic Community

Padgate House

Westcliffe House

Richards House

Turning Point (Hoole Road)

Stanfield House

Little Acre Care Home

Inward House Projects

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

CARE HOME ADULTS 18-65 Birchwood 23 - 25 Balls Road Oxton Birkenhead Wirral CH43 5RF Lead Inspector Helen Carton Key Unannounced Inspection 4th May 2006 09:00 Birchwood DS0000018870.V288034.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 DS0000018870.V288034.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 DS0000018870.V288034.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchwood Address 23 - 25 Balls Road Oxton Birkenhead Wirral CH43 5RF 0151 653 4266 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) Arch Initiatives Christina Maria Radford Care Home 14 Category(ies) of Past or present drug dependence (14) registration, with number of places Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2006 Brief Description of the Service: Birchwood is registered to provide care for fourteen adults with past or present drug dependence. The service is providing a detox programme with stays ranging between three and eight weeks. The service is comprised of two large adjoining three storey terraced houses and is situated in a mainly residential area next to a main road. It is close to shops, leisure facilities and within walking distance of Birkenhead town centre. All Bedrooms are single with lounges and the dining room being on the ground floor. There are bathrooms and shower rooms on both the ground and first floor. There is a large garden to the rear of the building and a small car park at the front. Birchwood charges £850 per week for accommodation and the specialist services it provides. Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process Birchwood sent the Commission a completed pre inspection questionnaire with information about the service being provided. Two site visits where made to enable the inspector to examine documentation, to discuss how the service supports clients and to discuss the day-to-day operation of the service with managers and members of the staff team. The inspector spent approximately seven hours at Birchwood. What the service does well: What has improved since the last inspection? Since the last visit to the service the manager, deputy and the staff team have worked hard to improve their record keeping including recording significant events in clients’ daily records. There have been few changes to the staff team since the last visit to the service this has helped to develop cohesive teamwork. The information held by Birchwood about the staff team has improved since the last visit. It clearly shows what checks have been made by Arch Initiatives prior to a person being offered employment. By having thorough recruitment procedures Birchwood is protecting clients’ from being taken advantage of or potential abused. Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 6 The staff team receive regular supervision from the management team, which offers them support and guidance to help them support clients appropriately and safely. 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. Birchwood DS0000018870.V288034.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 DS0000018870.V288034.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. Birchwood has produced good information about the service it provides. However the pre admission procedures are poor resulting in little forward planning being carried out prior to admissions. EVIDENCE: Birchwood provides clients and funding agencies with detailed information about the services being provided. This information is held in the Statement of Purpose, service user guide, residents handbook and client contracts. The inspector spoke to clients who felt they had been given good information about the service and had been told by past users of the service how well organised the detox programme was. The inspector discussed with the clients the resident handbook, which details the rules of the house including restrictions on their daily lives. Clients told the inspector they accepted the restrictions placed on them during their stay as it made them focus on their addiction issues. Pre admission assessments are carried out by a care co-ordinator who is employed by Arch Initiatives and works from their head office in Birkenhead. Samples of assessments were examined that were found not to hold sufficiently detailed information and which included generalisations of drug users lifestyles. Risk factors such as depression, self-harming behaviours and Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 9 suicide attempts or thoughts were not explored. The assessments did not hold information to assist the Birchwood staff team to provide appropriate support and supervision. This lack of information results in clients being asked the same type of questions on admission when they are vulnerable and should feel confident that Birchwood are aware of their needs and can support them. These issues of concern were discussed with the manager and deputy. The inspector advised the pre admission assessment should identify care needs and risk factors in enough detail to enable the staff team to provide appropriate support and supervision at the point of admission. It should also form the basis of care plans, risk assessments and management plans produced by the service. The lack of information does not enable the service to plan for admissions to ensure the staff team have the required skills and training. Particularly with regard to supporting individuals with mental health and acute emotional needs. Birchwood DS0000018870.V288034.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. Care planning and risk assessment systems have improved however further work is needed to ensure all care needs including emotional and mental health needs are appropriately supported. The service provides a highly structured environment that limits the ability of clients to make decisions in their daily lives. Clients agree to these restrictions prior to their admission and understand their responsibilities to the programme. EVIDENCE: A sample of care plans were examined and they identified care needs particularly those related to clients drug use. However information regarding recent episodes of depression, self-harming behaviours or suicide attempts or thoughts where limited with few management plans in place to guide the staff team as to the most appropriate support and supervision to be provided. Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 11 Entries are made daily in clients diary sheets with comments regarding clients physical and emotional state being made. One to one sessions take place a minimum of twice per week with confidential notes being kept with the full knowledge and co-operation of clients. Birchwood has a highly structured programme, which all clients must agree to fully take part in prior to their admission to the service. Each client has a designated key worker who is a substance misuse worker. Part of their role is to lead group work and provide one to one sessions. These activities are incorporated in the care plans and clients contracts as they are seen as a central part of the detox programme. As part of the programme care plans and risk assessments are reviewed every two weeks with clients, key workers and the deputy manager. This is designed partly to acknowledge to individual clients the progress they have made. Also to identify further needs, as they get closer to their time of discharge such as housing issues, rehabilitation programmes and planned counselling. As a detox unit Birchwood provides a highly structured environment for clients including mandatory house and group meetings and one to one sessions. Clients told the inspector when they arrived at Birchwood having to go to all the meetings wrecked their heads. But as they got into the programme they looked forward to the group and individual work. Clients felt restrictions placed on their ability to make decisions in their daily routines were annoying But made them feel safe as they were not allowed to leave the house or have people visiting them without permission from the managers. They told the inspector they needed to focus on their own issues and realised any external distractions were unhelpful. Birchwood DS0000018870.V288034.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. Birchwood provides appropriate types of leisure and personal development activities in line with the central ethos of the service. Staffing levels at the weekends do not fully meet the needs of clients staying at Birchwood. Clients on the whole are happy with the support and service they receive from Birchwood. EVIDENCE: Clients are admitted to Birchwood for a maximum six weeks to undertake a detox programme. Due to the type of service being provided restrictions are placed on clients’ movements and action in the house and in the community. All restrictions are shared with clients’ prior to admission if possible or during the admission process. They are given copies of the service user guide and house rules, admissions only take place after clients have signed their Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 13 contracts agreeing to take part fully in the programme and abide by the rules. These include daily house meetings, group work and one to one sessions with their key workers. Clients told the inspector they found the restrictions placed on them difficult at the beginning of their treatment programme, particularly the limited and supervised visits from family and specific friends. However as they progressed through the treatment programme they felt the restrictions placed on their daily activities and social contact gave them the time and freedom to concentrate on their addiction behaviours and to recognise the impact their addiction has on them as individuals and within their friendship and family groups. Clients told the inspector they “felt safe and supported” by the staff team. However on occasions particularly at the weekends there were not enough staff to support them to undertake leisure activities and to fully supervise visiting times. Clients also raised an issue about members of the staff team wearing their employee identification cards around their neck when accompanying them in the community. Clients told the inspector they felt this identified them to the public as drug users and that everyone knew their business. Clients asked the inspector to discuss these issues with the manager and deputy. The inspector looked at the staff rota for the week of the inspection, which showed only two members of staff on duty between 8am and 10pm. Due to the level of supervision and support required by the detox programme the staffing levels provided during the week seem disproportionate to those at the weekend. The manager and deputy acknowledged the feelings of the client group with regard to staff visibly wearing ID cards while supporting them in the community and would discuss this practice with the staff team. The need to ensure practice reflects the training provided and the ethos of the service with regard to issues of diversity and equality was also acknowledged. Completed questionnaires indicate overall clients are happy with the service being provided however the issue of staffing levels were highlighted. The inspector advised the manager to look at this issue to ensure clients are supported and supervised as effectively over the weekend period as in the week. Clients told the inspector they were happy with the quality, quantity and choice of the food and meals provided and that the cook asks them what they like to eat and will always offer an alternative. Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. On the whole the service supports clients with their personal and health care needs. However they remain poor at identifying mental health needs of clients and offering appropriate support and supervision potentially leaving clients vulnerable to the negative impacts of their conditions on their emotional and mental well being. EVIDENCE: Birchwood works within a multidisciplinary environment to support clients during their stay this includes a specialist GP visiting three times a week. There is regular contact with specialist services such as dental, district nurses, drug services and counselling services. Examination of a sample of records indicates Birchwood supports clients with their physical health care needs. However the service does not monitor or support clients effectively with mental health needs such as episodes of depression and self harming behaviours. The inspector discussed this issue Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 15 with the manager and deputy who acknowledged this is an area of support Birchwood needs to improve. They advised the inspector they were in the process of arranging mental health awareness training and were also reviewing information and the level of detail held in care plans, risk assessments and management plans. Clients told the inspector they found the one to one sessions with their key workers very positive and felt able to ask for more if they felt they needed them. The inspector examined a sample of clients medications and the accompanying documentation they were well maintained and organised. The service has provided external training for those members of the staff team who administer medication and are arranging further training to ensure the services medication procedures are in bedded in their practice. Due to the type of service being provided all medication is administered to clients in the medication room in the presence of two members of the staff team. With both staff members signing the medication administration record sheets. The home maintains a controlled drugs book and a returned medication logbook which the visiting pharmacist is required to sign. As part of the detox programme provided support is offered to clients with issues regarding housing plans, rehabilitation programmes and criminal justice system. The accident/incident book was examined and was appropriately maintained. Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. Birchwood proactively seeks the views of service users and deals with issues of concern in a sensitive and professional manner. EVIDENCE: Birchwood has a detailed complaints procedure which is included in the statement of purpose, service user guide and residents handbook. To ensure clients are fully aware of the complaints procedure during admission a member of the staff team will go through it with them. Since the last inspection visit the manager has instigated disciplinary action on three separate occassions and followed the correct procedures. The manager was advised to familiarise herself with the referral of people to protection of vunerable adults list. Since the last inspection visit one formal complaint has been made to the service resulting in an investigation being undertaken by a senior manager from Arch Initiatives, the complaint was not substantiated. The manager was advised to ensure details of the complaint and the outcome are recorded in the services complaints log. House meetings take place each morning with clients encouraged and supported to raise issues of concern or complaint. These meetings are minuted with the client group and the managers of the service are expected to respond to issues as soon as possible. Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 17 Since the last inspection visit the service has introduced a comments book for clients to use at the end of their stay to enable Birchwood to assess if the programme they are providing is meeting clients needs. The inspector viewed the comments book the following are a small selection; Thanks to all the staff in given me a chance to rebuild my life. Ive had a really good stay. The time I have spent here was good for me and thanks for treating me like a person. The staff are excellent and so are the residents but its just not my time yet. Everyone take care. Birchwood have arranged for a representative of Wirral Advocacy to visit the service and talk to clients on a weekly basis. General feedback is then given to the managers before the next visit. Birchwood also has a suggestions box in the hall which is emptied on a weekly basis by the managers of the service. The manager and deputy informed the inspector they operate an open door policy and encourage clients and the staff team to raise issues and seek clarification. Clients told the inspector they felt the manager and deputy were honest in their dealings with them and valued them as people as did the staff team. Birchwood have an adult protection policy and procedure and have a copy of Wirral social services protection of vulnerable adults protocols. The inspector advised the the manager to ensure the staff team are fully aware of the protocols and aware of their responsibilities. The manager told the inspector issues of protection of vulnerable people is addressed in the DANOS training and is a theme throughout the individual units. She also stated she intended to contact Wirral adult protection unit to find out if training was being provided on the new protocols. Birchwood DS0000018870.V288034.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. Birchwood provides a safe, homely and comfortable environment for clients to use during their stay at the service. EVIDENCE: Arch Initiatives continue to invest in Birchwood and significant improvements have been made in the physical environment. Improvements include new sofas and curtains in the lounge and new chairs in the meeting room. Work has been carried out in the rear garden with new sports equipment and garden furniture being provided for clients use. Clients told the inspector they felt comfortable and relaxed at Birchwood and enjoyed the facilities especially the garden in the good weather. Clients comment cards confirm this information. There is an expectation that clients will be involved in some domestic duties as part of their detox programme such as keeping their bedrooms clean and helping with the dishes after meals. Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 19 Areas of the service viewed were clean and tidy. Birchwood DS0000018870.V288034.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 & 36 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The organisation is showing a commitment to providing the staff team with appropriate training however shortfalls remain particularly with regard to mental health issues. The current deployment of the staff team does not meet the needs of clients. The staff team are appropriately supported and supervised by the management team. EVIDENCE: Arch Initiatives has a central staffing and recruitment section that deals with all recruitment requirements for the whole organisation including Birchwood. Since the last inspection visit the organisation has developed a pro forma which provides information as required in Schedule 2 of the Care Homes Regulations whilst holding the actual staffing records for confidentiality reasons at the organisations headquarters. Records were found to be appropriately maintained with evidence that all appropriate checks have been carried out. There have been no changes in the staff team since the last inspection. Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 21 The Pre inspection questionnaire identified the following training had been undertaken in the last twelve months: groupwork, care plans, key working, first aid, Drug and Alcohol National Occupational Standards (DANOS) and medicine management. Training records confirmed this information. Members of the staff team spoken to during the visit told the inspector they felt the specialist DANOS training they were involved with helped them look at issues regarding drug addiction in a more holistic way. Enabling them to see the individual not just the addictive elements of their peronalities. Both staff groups, the substance misuse workers - who are responsible for keyworking and leading group work, and the support workers - who are responsible for the day to day support of clients, were clear about their roles and responsibilites. Members of the staff team spoken to felt the manager and the deputy were firm but fair in their management style and were supportive and approachable. They confirmed they have regular supervision which looks at their practice, work performance and allows them to identify training needs. As detailed earlier in this document clients raised with the inspector issues of poor staffing in the evenings and weekends resulting in clients activities being restricted. This issue was discussed with the manager and deputy and the review of staffing levels will be a requirement of this inspection process. The staff team told the inspector they had not received specific training with regard to mental health needs and they felt this type of training would be useful. This issue was discussed with the manager and deputy who advised the inspector plans were being made to provide this training in the near future. Birchwood DS0000018870.V288034.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. Birchwood is managed well by an effective management team. EVIDENCE: The manager has been in post for approximately twelve months and has worked hard with the deputy to divide managerial roles and responsibilties to ensure there is an effect management structure in place. This system has promoted an environment of accountabilty and responsibilty which is being cascaded down to the wider staff team. The deputy manager due to his qualifications and experience takes the lead in planning the therapeutic programme operated at Birchwood and provides supervision to the substance misuse workers with the manager responsible for the day to ay management of the service, supervision of the support workers and to monitoring the overall quality and effectiveness of Birchwood. Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 23 The service is continuing to develop its quality assurance tools and can demonstrate that they are a service user led service that listens to and acts on comments made by users of the service. The services accident/incident book was examined and was appropriately maintained. The fire logbook was maintained with all required training and drills being undertaken in within the appropriate timescales. Birchwood DS0000018870.V288034.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 3 2 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 3 X Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? 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 YA2 YA19 Regulation 14 Requirement The registered persons must ensure the assessment protocols in place are reviewed to ensure they reflect the level and type of service provided to clients by Birchwood. The registered persons must ensure where risk factors are identified such as episodes of depression, self-harming behaviours or attempts or thoughts of suicide that detailed information and advice is sought and documented in clients care plans, risk assessments and if necessary management plans. The registered persons must ensure staffing levels provided meet the needs of clients with particular regard to staffing hours provided in the evenings and weekends. The registered persons must ensure that relevant specific training with regard to the mental health needs of clients is provided. A plan of how this is to be addressed must be provided to the CSCI within the stipulated timeframe. DS0000018870.V288034.R01.S.doc Timescale for action 30/07/06 2. YA6 YA9 13 30/07/06 3. YA33 18 04/05/06 4. YA35 18 30/07/06 Birchwood Version 5.2 Page 26 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 Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Birchwood DS0000018870.V288034.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!