Inspection on 11/07/06 for Birchwood House Rest Home

This inspection was carried out on 11th July 2006.

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

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

Other inspections for this house

Birchwood House Rest Home 22/07/08

Birchwood House Rest Home 03/03/08

Birchwood House Rest Home 27/11/07

Birchwood House Rest Home 15/02/06

Birchwood House Rest Home 14/06/05

Birchwood House Rest Home 20/12/04

Birchwood House Rest Home 24/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Birchwood House Rest Home Stockland Green Road Speldhurst Tunbridge Wells Kent TN3 0TU Lead Inspector Maria Tucker Key Unannounced Inspection 11th July 2006 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 House Rest Home DS0000023895.V301496.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 House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchwood House Rest Home Address Stockland Green Road Speldhurst Tunbridge Wells Kent TN3 0TU 01892 863559 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) Malvirt Limited Mrs Janice Eileen Collins Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: Birchwood House provides accommodation for up to 38 older people. The house is a detached property with accommodation on four floors, standing in its own large landscaped grounds. The home is located in a rural area on the outskirts of a small village. The nearest public transport, pub, church and post office are approximately one mile away. There is car parking to the front of the premises. All bedrooms have en suite facilities with WC, call points and TV points. Many rooms have telephone points. There is a shaft lift to all floors in the main house and a stair lift to the three rooms in the annex. A few rooms require access up stairs. There is no designated guest room but if a room is free, arrangements can be made for guests to stay overnight. Communal facilities include two lounges, a conservatory and dining room on the ground floor with a smaller lounge on the first floor. A domiciliary care service is run from offices in the house. The fees range from £475.00 to £650.00 per week. Extra charges for Hairdressing £8 or at cost; Chiropodist £12 or at cost; News papers and toiletries at cost. Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection lasting from 10 am to 5 10 pm. Time was spent talking with the manager, provider, administration staff and care staff. Service users were spoken with individually and collectively. Two relatives were spoken with; two visiting health professionals and a visitor conducting bible class reading. A partial tour of the building and grounds was undertaken. The pre inspection questionnaire has been received, as has comment / feedback cards from service users, health and social care professionals, visitors and relatives. Overall the feedback was very positive with some issued raised that were followed through during the site visit. What the service does well: What has improved since the last inspection? Staff recruitment procedures have been firmed up. Permanent staff are in the process of being recruited to replace the use of agency staff. Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 6 The care planning formats have been improved upon, they are in more detail to provide staff with specific guidance as to preferences and needs. The monitoring and recording of health needs has been firmed up providing a clear picture of medical appointments and outcomes. The designated clinical room when finished will provide a good working area for the management of medication. 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 House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 7 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 House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5, 6 Quality on this outcome area is good this judgement has been made using available evidence including a visit to the service. Service users can expect a full assessment of their needs to be undertaken prior to being offered a place at the home. EVIDENCE: The manager confirmed that the home does not provide intermediate care. Case tracking confirmed good practice. The manager visits prospective service users at their place of residence as part of the assessment process. A service users file contained a joint health and social care assessment and an assessment completed by the manager. The care plan was devised from information gathered. The care plan was brief yet comprehensive in the guidance and instructions for staff to follow. It had been reviewed at regular intervals as part of the settling in period where staff update information and care plans as they get to know service users and their needs and preferences. The manager explained this was because sometimes the assessments change when service users move in. This was confirmed by a relative who spoke of how prior to moving to the home their relative (service user) was visited in hospital where they had been admitted following some falls and generally not Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 9 coping. Joint discussions were held with the service user and relative on how things have improved greatly as when at home the service user was not coping and “did not have the incentive some days to get up and get dressed or socialise”. Since being at the home the service user has made vast improvements, including using the stairs instead of the lift (which they needed at first), as they were now stronger on their feet and being interested in their appearance. It was discussed that as the door is locked at 7 pm and night staff are busy supporting service users with nighttime routines this would be useful to put in the statement of purpose and service users guide so that visitors are aware that they may need to wait to gain entry. Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality on this outcome area is good this judgement has been made using available evidence including a visit to the service. Service users can expect to have their health and welfare promoted through good practice and understanding of needs in this area by competent staff working in partnership with the service users and health professionals. Environmental risk assessments in private rooms would enhance personal safety by identifying and potential individual risks. EVIDENCE: Service users care plans viewed were informative in the information contained. Care planning formats have been changed so that they are more comprehensive including Strengths / needs / objectives / actions recorded. The risk assessments conducted, as part of the care planning would benefit from being broken down into individual risks to provide clarity and be more specific in exactly what action to be taken to minimise risk. The formats need to reflect that service users and appropriate others have been included. Staff had a very good understanding into perceived risks and the balance between this and independence evidencing good sound judgements and knowledge of the needs of this client group. It was discussed that an environmental risk assessment on individual rooms should be undertaken to supplement the Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 11 mobility assessment. This is recommended as a good practice measure as many service users choose to spend some leisure time in their room. This would ensure that hearing, sight and mobility difficulties are considered in context and appropriate measures to reduce possible risks taken. Information from relatives on past history was contained in service users files this enabled staff to familiarise themselves with individual service users and consider life histories in the care delivered. Evidence from case tracking and document reading on support needed and given correlated to the daily records. Good evidence that staff are familiar with service users individual lifestyle was noted by a daily entry in an individual note that a service user was “Not (their) usual self, did not have TV on”. This was discussed with the manager as it was recorded in the care plan that watching a particular programme was a hobby and this had been noted because it was out of character not to have this on. The manager had checked out with the service user that all was well with them. Evidence from discussions with a relative on the health needs prior to moving into the home and the improvements made to the service users health and welfare since being at the home that health promotion and needs are met. Comments made by the relative included “Very happy, very strong on their feet now, interested in appearance, at home did not get dressed some days, quality of life is fantastic”. The service user reiterated by comments made that “The staff are absolutely wonderful, it’s a wonderful place, nothing is too much trouble”. A service user spoke of their current medical treatment, detailing what the Doctor was concerned about and what action and treatment they were having. Staff were fully aware and supportive giving reassurance during the conversation as well as commenting on the service users pro action in managing and taking responsibility for their health. Staff were seen throughout the day to be meeting and promoting the health and welfare of service users, examples of staff interaction included a staff member talking with a service user stating “I think you need a drink” another example “Would you like this open (door) get a bit of fresh air”. It is the home’s philosophy to enable service users to live in the home for the rest of their life as Birchwood house rest home is ‘their home’ and as stated by the Provider “As long as we have the support of family and GP we keep them here”. Many service users have been resident for a considerable time. Discussions with a visiting District nurse and health care assistant that service users health needs are met via health professionals. That service users are seen in their own room, that dressings and medical equipment are kept by the service user as stated by the district nurse it was “Quite nice it is in their own room”. Currently the home was said to have no one with particular health needs, only minor ones and the home phone and refer when needed. The medication administration was observed with good practice adhered to. The medication was found to be stored appropriately and procedures followed i.e. mar sheets signed, records of medication received. The laundry room has almost been converted to a treatment room which when finished will enable medication to be organised and managed within a good working area. It was Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 12 discussed that the PRN medication needs firming up as no directions as to how much to give, when and what it was given for. Staff were very familiar with this and records had been made at the time of medication being prescribed. It was discussed that this information should be readily assessable i.e. with MAR sheets and staff need to be sure that they and service users understand and check this out when administering medication. Self-administering of medication is promoted through risk assessments being done and based on competency and choice. Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality on this outcome area is good this judgement has been made using available evidence including a visit to the service. The home offers a high quality service that promotes and enables service users to lead a full and rich life style suited to individual needs, choice and preferences. EVIDENCE: The home has many areas for service users to sit and relax or undertake hobbies in these include 3 lounges a beautiful conservatory and well-kept garden. Service users were seen throughout the day to be wandering freely around the home and grounds making use of the space while interacting and socialising with each other. A service user spoke of their morning routine, how they had breakfast in bed, took a rest and then got up in their own time and pace commenting, “I had a nice bath, then they put my dressing gown on”. Another service user spoke of the daily routine as being flexible. Without exception all service users said how nice the food was how they were given choice and alternatives, comments from service users included “Very good food” “Cook very approachable” and the “food is the best thing”. The menu offers a good variety and selection of home cooked food with fresh vegetables. Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 14 Activities were varied and service user are consulted on what they want and encouraged to take part. One service user said they “Spend most of time in room through choice comes down for activities” another said the home was “Just starting art and craft club” service users are encouraged to be participants with one service user playing the piano for hymns Sunday morning. Activities on offer include 3 yearly parties at Easter and Christmas so that service users can have families visit as they would in there own home. There is an annual open day where the local community is welcome, last year the manager stated many locals attended. Although service users were aware of what was happening and when, it was discussed that these could be advertised weekly on an activities board for all to see and choose which would also aid in visitors being able to plan their visits around events. Bible reading stories were being held in the lounge. The inspector was invited to join and take part where good interactions and attendance by service users was noted. A relative visiting explained how their relative (service user) was seated outside the office in the lounge describing staff as “very good here” how the interaction with the service users was very good, as they were partially sighted and staff make contact with touching their arm / knee and speaking to them when they go past. Staff and relatives were relaxed and confident with mutual respect and Very good interaction noted. All service users are treated as equal irrespective of the funding arrangements. Staff know likes and dislikes these are recorded. Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, Quality on this outcome area is excellent this judgement has been made using available evidence including a visit to the service. Service users can feel confident that they will be well looked after and cared for by competent professional staff that have the service users best interest at heart. Good management policies, procedures and staff training back that this up. EVIDENCE: Comments received in the comment card indicated that service users and their families would if they had any concerns feel able to make these. During the inspection service uses were asked if they had any complaints or if there was anything that they would like or could improve the home. Without exception all were very happy and could not think of anything they would change. The manager and staff are pro active in seeking service users views to ensure that they are well and have no complaints. There have been no adult protection alerts raised. The home only supports 1 service user with their personal spending. Good systems to monitor and audit this are in place. Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality on this outcome area is good this judgement has been made using available evidence including a visit to the service. Service users live in a pleasant and safe environment that is homely and individual to taste. EVIDENCE: Birchwood house rest home was found to be in a good state of repair, clean and tidy with no offensive odours. The décor is in keeping with the home style and period features providing a homely ambience that the service users appreciate. The garden provides a walking area that service users were seen to be enjoying, and a view for others to sit and admire. The dinning room was found to have all chairs and tables matching and although a bit scratched around the bottom of the wood were in a good state. Service users rooms were individual to taste and contained plenty of personal effects. Service users spoke of how they choose to spend time in their room one stating “I love my room” another spoke of how they chose their room as it is small and can find way around it. Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 17 The lounge areas were comfortable with plenty of equipment for activities including a piano, television and books and games. The grapevine and bougainvillea in the conservatory gives an outdoor feel that service users and relatives were sitting in and enjoying, it has steps leading into the garden area, a separate door has a level access to a patio area. There are three bathrooms, two with a parker bath and one a standard bathroom whish staff stated was not used much. Each room has its own toilet and washbasin. A toilet is sited near to the communal areas with a separate toilet for visitors and staff. An assistance call system is fitted. The front door is locked at 7 pm for security reasons. Radiators and hot water pipes that have been risk assessed as presenting a risk have been covered. The majority of radiators can be controlled by the room’s occupant. There are fans available and doors and windows were open for ventilation. The conservatory does get hot and the manager explained that they prefer not to have a fan in it because of the risks of dehydration. Staff encourage service users to stay for a short time and support those who need assistance to move to other areas. This was noted to occur throughout the day with staff assisting service users to move and providing regular drinks to service users. The laundry room has been recited and a clinical room is in the process of being finished off where the laundry room was. Both areas are cluttered while this work is being finished. The Environmental Health Officer has visited leaving a positive feedback and report. Concerns were raised in the feedback comment cards about the cleanliness of some of the individual rooms. This was discussed with the manager who explained that they were having difficulties in recruiting a regular cleaner and had been using agency staff. Agency staff were seen cleaning the rooms. The rooms seen were clean and tidy. It was explained that building work opposite has led to excessive dust and more robust cleaning needed. Some service users spoken with chose to keep their rooms clean with staff maintaining the bathrooms and hovering. The home is large and the upkeep for maintenance and renewal of items and equipment ongoing with areas redecorated as needed to a high standard. Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality on this outcome area is good this judgement has been made using available evidence including a visit to the service. The home has a good complement of well-trained and motivated staff who provide a high quality service. EVIDENCE: The staffing levels in the home are according to the rota consisted of 4 care staff in the morning and 3 in the afternoon / evening. Shifts run from 7 am to 1pm and 1 pm to 7 pm with some staff working long days. There are 2 waking night staff. There is a senior staff on duty for each shift, the manager works mainly during the day, as does the new administration staff member. The Pre Inspection Questionnaire provides a client list with key workers named. The staff list consists of the Manager; head of care; team leaders x 2; senior carer; care assistant x 10; cook; cleaner x 2; gardener. With 6 service users identified as having medium needs, 16 service users as having low needs. The DOH residential forum calculations 390.63 total care; 496.94 total duty; 12.42 waking full time staff. Service users and relatives spoke very highly of the staff team comments made included “The staff are absolutely wonderful” and the home is a “proper family”. Throughout the inspection staff were seen and heard to be courteous and respectful towards service users, which was mutually reciprocated. Staff are of a high calibre and the manager expects high standards from all staff. Agency staff are used to cover shifts although a recent recruitment drive is expected to reduce the need for agency use. The same regular agency staff are used for consistency. The manager confirmed that all agency staff are Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 19 trained to NVQ 2 and receive regular training via the agency. The agency completes all the necessary checks when recruiting. Staff were familiar with individual needs and preferences and had a good insight and understanding into the needs of the service user group. The home has 9 care staff NVQ 2 or above and have met the standard of 50 care staff trained. Staff files inspected were complete and evidenced the home has a good robust procedure for recruitment of staff. The staff-training matrix seen on the computer was being developed with information being entered. The Manager confirmed all mandatory training has taken place and further training as booked. Staff files contained copies of training certificates. It was advised to put a monitoring / tracking form in front of staff files for efficiency purposes. Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 Quality on this outcome area is good s judgement has been made using available evidence including a visit to the service. The home is well run and managed with safe systems in place to ensure the service users receive the benefit of living in a home that is run in their best interest. EVIDENCE: The manager has worked at the home for some 7 years, holds qualifications relevant to care and management and has many years experience in the care field. There is now a deputy manager in place and an administration staff to support with the office work and overall general management. Staff have designated areas of responsibility and work closely as a team. There is an open ethos between managers and staff. Questionnaires for relatives and service users have been completed with evidence that items raised had been acted upon. It is planned that a Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 21 newsletter would be put together to feed back the results. Overall the feedbacks were very positive. Service users confirmed meetings are held. Minutes of a recent meeting were seen. The Manager stated that she speaks to everyone individually every week as part of the quality assurance and general good management. The home does not act as appointee for any service user. They do support with personal spending for one service user, this is audited 6 monthly and records and receipts kept. Staff confirmed that regular supervision takes place. The maintenance and associated records in the Pre Inspection Questionnaire lists fire officer visit Nov o5; fire equipment manufacturers Jan o6; fire drill/lecture/test 06; health and safety dep visit Feb 06; EHO visit Feb 06; central heating system 2/8/05; legionella temp check monthly; approved electrical contractor 17/11/05; electrical wiring cert 3/6/03; emergency lighting 13/2/06; lift engineer 19/1/06; hoist bath mobile wheelchairs 19/5/06; emergency on call, serviced on call; COSH, yes Sharps, Yes weekly. Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 22 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 23 NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that the risk assessments conducted, as part of the care planning would benefit from being broken down into individual risks to provide clarity and be more specific in exactly what action to be taken to minimise risk. The formats need to reflect that service users and appropriate others have been included. It was discussed that an environmental risk assessment on individual rooms should be undertaken to supplement the mobility assessment. It was discussed that the PRN medication needs firming up as no directions as to how much to give, when and what it was given for. It is recommended that an up to date list of activities detailing times and events be placed on display. 2 3 OP9 OP12 Birchwood House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 House Rest Home DS0000023895.V301496.R01.S.doc Version 5.2 Page 25 - 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!