Inspection on 12/04/07 for Birchwood Grove

This inspection was carried out on 12th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Grove 12/10/08

Birchwood Grove 09/10/07

Birchwood Grove 21/08/06

Birchwood Grove 15/11/05

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

CARE HOMES FOR OLDER PEOPLE Birchwood Grove 64 Sydney Road Haywards Heath West Sussex RH16 1QA Lead Inspector Mrs J Hough Key Unannounced Inspection 12th April 2007 09:30 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 Grove DS0000065773.V332522.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 Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchwood Grove Address 64 Sydney Road Haywards Heath West Sussex RH16 1QA 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) 01444 458271 01444 441 792 www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited vacant post Care Home 24 Category(ies) of Dementia (24), Mental disorder, excluding registration, with number learning disability or dementia (24) of places Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th January 2007 Brief Description of the Service: Birchwood Grove is a care home providing personal care and nursing for elderly persons with dementia and other mental disorders. The home admits residents from the age of 50 years upwards provided they are assessed as requiring care for mental health problems. The registered providers are Ashbourne (Eaton) Limited. Birchwood Grove is a large detached house in a residential area of Haywards Heath; 5 minutes walk from the local railway station and town centre. The residents accommodation is situated on the ground and first floor accessed by a passenger lift. There are 20 single bedrooms and 2 double bedrooms, 14 of which offer en-suite facilities. There are two lounge and dining areas and a garden at the rear, which is accessible to the residents and limited parking space to the front of the property. The responsible individual on behalf of the company is Mrs Angie Knight. The post for the registered manager is vacant. Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection was undertaken by Ann Peace and June Hough Regulatory Inspectors on the 12th April 2007 from 08:30 hours to 14:30 hours. Information for the planning of the inspection was taken from the preinspection questionnaire completed by the previous manager and evidence gained from previous inspection reports and information held on file. Further evidence for the inspection report was gained during the site inspection visit. The Registered Managers post is at present vacant and a previous manager of the home is overseeing the management of the home until a new manager is appointed. The deputy manager was present at the inspection and provided the information required. During the inspection the inspectors toured the premises, visited the resident’s rooms and observed residents in the communal areas. A case tracking exercise was undertaken for four residents that included looking at resident’s care records. Other records were examined in relation to complaints, accidents, medication, staff rota’s, staff files and training records. The inspectors spoke with staff working on the day, a visiting general practitioner and a small number of residents who were able to give a limited response and opinion of the home. Nine requirements were made following the inspection site visit, four of which were immediate requirements. Current scale of fees is: - from £675.00 to £675.00 per week. What the service does well: What has improved since the last inspection? Some armchairs have been replaced and new carpets fitted in some areas of the home. Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 6 What they could do better: Immediate requirements were made for the following. The need for staffing levels to be increased to meet the needs of residents. Evidence showed that medicines were not always given to residents at prescribed times. Meals are often served late to residents with long periods of time between meals and no evidence of them having regular drinks. Residents being left in bed later than they wish and being left unsupervised in the lounge areas. Residents were not being assisted to have a bath or shower as recorded on care plans and staff confirmed this was due to the shortage of staff. The hand washbasin in bathroom one to be made safe as it was broken with jagged edges. During a tour of the premises it was noted that only corridors and communal areas and laundry were kept clean. Resident’s rooms, bathrooms and toilets were dirty and unhygienic and looked as if they had not been cleaned for a long time. The deputy manager confirmed that there had not been a cleaner at the home for 6 months. There was no fire safety training records available to evidence that staff working at night and during the day had been receiving appropriate training. Staff spoken with who worked during the day confirmed they had received training but could not confirm dates. Requirements made following the site visit. There was no evidence that all staff have received training on how to care for people with dementia. Menus showed no evidence that an alternative meal was offered to residents and on the day of the inspection all residents were given chicken korma and the quantity of food cooked on the day meant there was none left over if residents wanted more. Kitchen staff were not aware of the food likes and dislikes and nutritional needs of residents. Residents who needed assistance with their eating were given their meals when staff were available that meant some of them ate their meals late. Care records need to improve in order to given evidence that resident’s needs are being met and the health and safety of residents is safeguarded. Care plans and assessments completed were not consistent in identifying resident’s needs and therefore care plans bore little or no relevance to the care Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 7 needed or given. Other care records such as daily records, fluid and turning charts were not always fully completed. Resident’s are not given opportunities for stimulation through leisure and recreational activities taking into account their interests and capabilities. Residents were observed sitting in the lounge areas sleeping or roaming around endlessly. There was no evidence that residents have any opportunities for stimulation and there is no activity organiser employed. Care staff are responsible for providing activities but due to staff shortages are unable to give the residents the time needed. The home only has two adjustable nursing beds and some residents are being nursed on inappropriate beds. 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 Grove DS0000065773.V332522.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 Grove DS0000065773.V332522.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. All residents have a needs assessment carried out prior to admission to the home although assessments did not in all cases reflect the care being given. EVIDENCE: Prospective residents have a needs assessment completed prior to moving into the home. However, evidence gained during the inspection site visit and looking further into care records showed the assessments did not reflect the care needed and the care being given. Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 10 Birchwood Grove DS0000065773.V332522.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 poor. This judgement has been made using available evidence including a visit to this service. Resident’s health, personal and social care needs are not being met due to the shortage of staff. Care records are poorly maintained and are not consistent in identifying resident’s needs. Medication policies and procedures are in place but observation of the administration of medicines showed that residents do not receive their medicines at the prescribed times putting the health and welfare of residents at risk. Evidence and observations on the day showed that residents are not always treated with respect. EVIDENCE: Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 12 Four resident’s care plans and assessments were examined and it was apparent that new records had been completed since January 2007. Risk assessments are carried out as necessary. However, on further checking records and evidence found when visiting residents in their rooms it was found that records were contradictory as assessments and care plans had little or no relevance to the care being provided to residents. Records examined did not give evidence that the resident’s needs are being met. Risk assessments are not followed through, for example a nutritional assessments identified the nutritional needs of residents that included their likes and dislikes in food but this information was not communicated to the kitchen staff. For example it was identified that one resident was a high risk of choking and the care plan states that assistance with eating and drinking is required, needs food supplements and cannot be left for long periods. There was no written evidence that these regular checks are carried out and there were no fluid charts as evidence that food supplements are given. Care plan states weekly monitoring of weight but this was recorded monthly. Another risk assessment showed a resident had sustained an injury from bed rails but the assessment was not dated and no action recorded to prevent this happening again. Daily records and fluid charts seen were incomplete. It was noted that one resident’s care plan states a weekly bath or shower but daily notes showed that the resident had not had a bath or shower since October 2006. We were told that staff did not have time to give residents baths or showers. One resident who stays in bed all day and is immobile was assessed as a low risk for developing pressure sores. Other records contradicted this as the resident’s dependency rating was very high and moving and handling assessment high. The nutritional assessment shows a risk of malnutrition and a risk of choking. There were no records to evidence that the resident’s position was changed regularly, fluid charts were incomplete, and there was no suction machine available in the home. One resident found calling out for assistance at 10.15 hours was still in bed although wanted to get up and had not yet been offered breakfast. The resident’s call bell was found to be out of reach. The home has two adjustable nursing beds and some residents are being nursed on inappropriate beds. Pressure relieving mattresses are used for those residents assessed as high risk of developing pressure sores. However it was noted that in some cases these mattresses are placed on inappropriate beds and were hanging off the end of the bed, and in some cases are not inflated at the correct pressure. Mouth swabs were seen left lying on a table and one nebuliser being used by a resident was dirty and unhygienic. Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 13 As previously mentioned in this report there are two residents who are at risk from choking and there was no suction machine available in the home. However on the day of the inspection a new suction machine was delivered although the trained staff said they would not use it without having training on its use, therefore placing residents at potential risk On the day of the inspection the medication round was not started until 09.45 hours and did not finish until after 11.00 hours. Therefore resident’s medication that should have been given at 08.30 hours was not given at the correct times, although the medication administration records are signed as being given as prescribed. The delay in giving residents their medication on time was blamed on staff being busy. Evidence and observations on the day showed that residents are not always treated with respect. One call bell was found pinned behind a curtain out of reach of the resident, and one resident was given tea instead of coffee as requested as there was no coffee on the breakfast trolley. It was observed that one resident who needed help with eating was left with breakfast on a tray that they could not manage and later the tray was seen taken away by staff with food untouched. Observation of staff showed that they did close doors when providing personal care to residents and did speak to residents in a caring manner. Birchwood Grove DS0000065773.V332522.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 poor. This judgement has been made using available evidence including a visit to this service. There was no evidence available that routines of daily living are flexible and varied to meet the preferences and capabilities of residents. The home has no programme for activities therefore residents are not given opportunities for stimulation. Residents are not receiving a choice of meals at the times convenient to them. Residents likes and dislikes in food were not communicated to the kitchen staff. EVIDENCE: It was confirmed by staff that residents are woken, washed and dressed when staff can do it and not when the residents would like. Their preferences before admission were not documented so staff would not know their usual routines and habits. Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 15 At present the activity co-ordinators post is vacant and it was confirmed that the care staff are responsible for providing the activities. On the day of the inspection residents were sitting in the lounge areas sleeping or roaming endlessly around, with no opportunities for stimulation. Late on in the morning some residents were still isolated in their rooms waiting to get up. Staff spoken with said they would love the time to sit with residents but due to the workload they are unable to give residents the time and attention they need. A recent relatives meeting held in March 2007 highlighted concerns from relatives about the shortage of staff and the lack of supervision of residents sitting in the lounges. A sample of menus showed that the food offered is well balanced. However menus showed no evidence that an alternative meal was offered as on the day of the inspection all residents were given chicken korma. The quantity of food cooked on the day meant there was no food left over so if residents wanted a bigger or second helping no more chicken korma was available. On speaking with the kitchen staff they were not aware of food likes and dislikes of residents and the chef had no information with regard to special diets or nutritional needs of residents. One resident’s nutritional assessment showed they did not like certain foods but liked finger food. The chef was unaware of this and when asked about finger food said sandwiches and sausages would be offered. It was noted on records that several residents required a soft or pureed diet. On looking at menus chicken nuggets and chips was the meal on offer for one of the days. On speaking with the chef it was said that this would be mashed for residents needing a soft diet. The only qualification the chef on duty that day had was food hygiene. Due to the lack of staff residents were still being assisted with lunch at 2.20pm in the lounge and it was confirmed that three residents were still waiting for lunch. The pre-inspection questionnaire shows that most of the residents require assistance with their eating. The dining room only seats eight residents so other residents have to sit in the lounge chairs to eat. Breakfast includes a choice of cereals and toast. On the day of the inspection breakfast was served from an open trolley with food uncovered and the toast was cold and soggy having been on the trolley for some considerable time. Birchwood Grove DS0000065773.V332522.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 poor. This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place although complaints are not recorded giving the investigations, actions and outcomes. Although staff demonstrated an understanding of abuse residents remain at risk due to the lack of appropriate training. EVIDENCE: The home has a complaints procedure in place. The complaints log was seen and complaints included issues around the cleanliness of the home, staffing numbers, residents being left unsupervised in the lounge areas. Evidence gathered during the inspection shows these complaints have not been addressed. Complaints were not recorded clearly giving the investigations, actions and outcomes. Some entries were difficult to read and actions stated referred to operational manager with no further details. An Adult Protection investigation is still under investigation. Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 17 There was no evidence available that all staff has had recent training on the Protection of Vulnerable Adults (POVA). However staff spoken with understood the different types of abuse and what actions they needed to take in the event of any incidents in the home. Birchwood Grove DS0000065773.V332522.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 poor. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is dirty, unhygienic and poorly maintained. The garden and grounds are overgrown and untidy. Residents live in a home that is dirty, unhygienic and poorly maintained. The garden is overgrown and untidy and unsafe for residents. The laundry area is clean and tidy. EVIDENCE: Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 19 There is no programme of routine maintenance within the home although it was confirmed that a painter and decorator is due to start work within the next few weeks. New carpets have been laid in the corridors and areas of the home. While touring the premises it was noticed that corridors are kept clean by staff but resident’s rooms were dirty and untidy and many smelt unpleasant. On closer inspection it was noted that clean bed linen had been put on wet plastic sheets covering mattresses where residents had been incontinent. The deputy manager said there had not been a cleaner for six months but care staff cleaned communal areas but did not have time to clean other areas. A new cleaner has apparently been appointed and is due to start work in the near future. An agency domestic was booked by the deputy manager on the day of the inspection and arrived mid-afternoon that day. Accessible washing and toilet facilities are not adequate to meet resident’s needs. One bathroom was being used, as storage area and cleaning chemicals were not stored securely putting residents at risk. A shower room, which staff said is used, was dirty and unhygienic and it did not look as if it had been used for some time. The washbasin had a large jagged edged hole in it and was considered unsafe for use. An immediate requirement was made for this to be made safe. Another bathroom on the first floor was also very dirty and unhygienic with a cracked bath and broken hot water tap and looked unused. Another toilet was also dirty and unhygienic for use. Sluices in the home were dirty and cluttered and would have been difficult to use. Safe infection control practices are not being adhered to in the home with areas of the home being dirty and unhygienic, bins overflowing with clinical waste and not all care staff being dressed appropriately and not wearing protective aprons and gloves as required. The home is not well furnished and many bedrooms containing divan beds are in poor condition and most headboards are dirty and stained. Some new armchairs had been purchased but in the two lounges two chairs were really dirty and heavily stained. Rooms that were empty had not been cleaned and dirty linen left on beds. Some rooms visited had a mattress on the floor beside the bed for residents at risk of falling that were dirty. Screening is provided in shared rooms but screens are old and in poor repair. Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 20 The grounds and garden are untidy and overgrown with the patio area being used for old equipment and left over carpet. The path around the home was strewn with rubbish. A new laundry assistant is in post and the laundry facilities were clean and tidy and equipment available was suitable for the size and number of residents accommodated. Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 21 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 poor. This judgement has been made using available evidence including a visit to this service. The numbers of staff is not meeting the needs of residents. Domestic staff are not used to ensure the home is maintained in a clean and hygienic state. Recruitment practices and procedures in the home do not protect residents from harm. EVIDENCE: Staff rota’s seen were untidy and unclear in places with many alterations. On the day of the inspection there were two trained nurses and three care assistants on duty to look after sixteen residents, with thirteen residents being assessed as high dependency. One of the care assistants was also seen doing some cleaning duties as no domestic staff were working. The pre-inspection questionnaire showed that the staffing numbers at night have been increased from March 2007 with an extra care assistant. Agency staff are used to work available shifts. According to the duty rota for the following day there was only one trained nurse all day plus a further trained nurse working from 7am to 11am and one care assistant. The deputy manager did say she had more staff working, but the rota did provide evidence of this. Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 22 Staff spoken with said the staffing levels had been low for some time and they found it increasingly hard to meet resident’s needs. Staff morale was very low due to staffing levels and also the lack of any leadership within the home. At present the previous registered manager oversees the running of the home. The pre-inspection questionnaire shows that three members of the care staff have gained the National Vocational Qualifications in Care (NVQ). Three staff files were looked at for new members of staff. Files contained evidence of two written references and a Protection of Vulnerable Adults (POVA) checks prior to staff working in the home. There was no evidence in any of the files of a satisfactory Criminal Records Bureau (CRB) check being received. Two new members of staff are the laundry assistant and maintenance man who are both working in the home unsupervised. Although they do not provide personal care to residents they have contact with residents. The third new member of staff is a trained nurse who started work in the home in September 2006 and on some shifts is left in charge of the home. It was confirmed by the deputy manager the home has three staff vacancies for care assistants and a new manager has been appointed and is starting shortly. Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 23 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 poor. This judgement has been made using available evidence including a visit to this service. Resident’s health, safety and welfare is at risk due to the lack of leadership in the home, poor staffing levels, lack of staff training, and poor record keeping. EVIDENCE: There have been some changes to the management of the home. The previous registered manager was promoted within the organisation and a new manager was appointed but left after a few weeks. The previous registered manager of the home has taken on responsibility of the home until the newly appointed manager commences work in the near future. Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 24 The deputy manager was in charge of the home on the day of the inspection and could not clarify if any of the night staff had received updated fire safety training. Day staff confirmed they had training but could not remember when. There were no staff training records available to evidence fire training had taken place. An immediate requirement was made that fire safety training be commenced and to ensure staff on duty that day and those working that night receive training. A Regulation 26 visit had been carried out the previous day to the inspection and it was confirmed that fire-training records could not be found then, but this was not followed up by the person carrying out the visit and was mentioned in the monthly report. There was no evidence that the home operates a regular quality assurance system. Surveys from the Commission of Social Care Inspection (CSCI) sent prior to the inspection for distribution, were still in the office. A relatives meeting was held in March 2007 and concerns were raised about staffing levels, cleanliness of the home, and residents being left in the lounge areas unsupervised. The manager told relatives that agency staff would be used to increase staffing levels. Staff spoken with said there has been a general lack of training of late but future training is planned for care planning, challenging behaviour, privacy and dignity and training for a manual handling trainer. The pre-inspection questionnaire and training records gave no evidence of staff having any specialist training with regard to caring for people with dementia. There was evidence that some staff had training last year on challenging behaviour that consisted of watching a video. A maintenance man was appointed in February 2007 and is responsible for completing in house maintenance checks and is awaiting training on how to fit and check bed rails. The pre-inspection questionnaire shows that equipment used in the home was checked in January and February 2007. On checking the accident book it was seen there have been a high number of accidents in the home. It was concluded that no pro-active action is being taken to minimise the risk of residents falling and staff are reacting to residents falling with the use of crash mats. Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 25 Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 26 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 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X 2 X X 2 X 1 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X 2 2 1 x Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 27 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 OP27 Regulation 18(1)(a) Requirement Suitably qualified and competent staff should be working in the care home in such numbers as are appropriate to meet the resident’s needs and to protect the health and safety of residents. Immediate Requirement 2 OP21 23(2)(b) The hand washbasin in bathroom 1 to be made safe. Immediate Requirement 3 OP38 23(4)(d) All staff must have suitable training in fire prevention. Immediate Requirement All areas of the care home shall be clean and hygienic and reasonably decorated. Immediate Requirement Staff should receive training appropriate to the work they perform. Residents have a choice of suitable wholesome food in DS0000065773.V332522.R01.S.doc Timescale for action 14/04/07 14/04/07 14/04/07 4 OP26 23(2)(d) 14/04/07 5 6 OP38 OP15 18(1)(c) 16(i) 31/05/07 30/04/07 Birchwood Grove Version 5.2 Page 28 adequate quantities and at times suitable to them. 7 OP7 15(1) Care plans, assessments and all care records in the care home must be improved in order to give evidence resident’s needs are being met and the health and safety of residents is safeguarded. Residents must be given opportunities for stimulation through leisure and recreational activities taking into account their interests, wishes and capabilities. The home must provide adjustable nursing beds for residents that are being nursed. 31/05/07 8 OP12 16(2)(n) 31/05/07 9 OP24 16(2)(c) 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Birchwood Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Grove DS0000065773.V332522.R01.S.doc Version 5.2 Page 30 - 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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