Inspection on 22/07/08 for Birchwood House Rest Home

This inspection was carried out on 22nd July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Birchwood House Rest Home 03/03/08

Birchwood House Rest Home 27/11/07

Birchwood House Rest Home 11/07/06

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Birchwood House Rest Home Stockland Green Road Speldhurst Tunbridge Wells Kent TN3 0TU Lead Inspector Gary Bartlett Unannounced Inspection 22nd July 2008 08:45 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.V367354.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.V367354.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 Ltd 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.V367354.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2008 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 £236 (local authority shared room) to £700.00 per week. Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in Birchwood House on 22nd July 2008 from 8:45 am until 3:30 pm and on 29th January 2008 from 3:00 pm until 5:00pm. During that time the Inspector spoke with some residents, a visitor, the home owner, the Manager and some staff. Parts of the home and some records were inspected and care practices observed. Residents and their relatives say they like the home and think there are generally good standards of care. Comments included: • “I am very satisfied with the care given here”. • “This is a lovely place to live”. The Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older People refer to people who use the service as “service users”. People living at Birchwood House prefer to be referred to as “residents”. Accordingly this shall be done in the text of this report. The Inspector would like to thank everyone involved for their contribution to the inspection. What the service does well: Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 6 Residents say they enjoy living at Birchwood House and are happy here. They say the staff are kind and caring. There is an open, relaxed and friendly atmosphere with good interaction between residents, staff and visitors. Residents enjoy the meals which are of good quality. Personal health care needs are well supported and residents’ individual preferences are catered for where practicable. There is encouragement for residents to partake in activities suited to their preferences and capabilities. Information about the home is easily accessible. Staff recruitment process are robust to ensure only appropriate people work at the home. Staff are encouraged to undertake training and receive supervision. What has improved since the last inspection? Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 7 A new Manager has been appointed, as well a Deputy Manager. They now have the support of a part-time Administrator. The Manager has initiated a major overhaul of all the care plans. The new format is much better organised with important information about general health care needs more readily accessible to staff and good information about people’s social history to help staff provide sensitive support to people who live in the home. Residents have improved access to healthcare support. The storage of medicines is much improved since the last key inspection. There are now risk assessments for self-medicating residents. Residents are able to go on more outings. More training is available to staff and there are better systems for monitoring staff individual training needs. Staff have more regular supervision. Staff files are better organised. Residents’ meetings are being held more regularly to give them the opportunity to make their views known. There are new policies and procedures. What they could do better: Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 8 A lot of progress has been made in a short time. The next hurdle for the home is to ensure this is consistently translated into good daily practice by all staff. For example, ensuring hazardous substances such as cleaning chemicals are never left out unattended. The care plans need further work to clearly identify residents’ individual specialist care needs such as dementia and depression. How are these frailties present and how they should be cared for with a direct link to monitoring findings. Daily records of care should be more informative and give clearer evidence of monitoring service users’ specific care needs. There have been improvements to the risk assessments but further work is required for them to more fully encompass activities undertaken by residents. For example, going out independently. Replacing or making good worn and damaged carpeting that is a trip hazard and ensuring all support frames around toilets are secured will help reduce risk of injury to people. Improved laundry facilities should be provided to better enable a separation of clean and soiled items and maintain infection control. The quality assurance questionnaire should be developed to include space for free text to give people better opportunity to say what they think of the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 9 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.V367354.R01.S.doc Version 5.2 Page 10 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): 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Birchwood House has good pre-admission procedures so that residents can be confident the home can meet their needs. EVIDENCE: The Manager described how a pre-admission assessment is made of each prospective resident. The assessment process includes recording the findings of the assessment, the detail of which then informs the initial care plan. She said prospective residents, their families, advocates, and relevant health care professionals are involved in the assessment process. Specialist advice is sought from external sources where required. Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 11 The Manager understands that pre-admission assessments must account of staff skills and said she is arranging for staff to be trained where necessary. Residents said they or their families had been able to visit the home before moving in. They also said staff had been very helpful in assisting them to settle in. The home offers periods of respite care when a room is available. Intermediate care is not offered at Birchwood House. Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 12 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): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further improvement to care plan records would better show how residents’ individual care needs are to be met. The home liaises with health care professionals to help meet residents’ health needs. Staff treat residents with respect and maintain their privacy and dignity. EVIDENCE: Each resident has a care plan. The Manager has been in post for a short while and has initiated a major overhaul of all the care plans. Three were inspected in detail. The new format is much better organised with important information about general health care needs more readily accessible to staff and good information about people’s social history to help staff provide sensitive support Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 13 to people who live in the home. They now need further work to clearly identify residents’ individual specialist care needs such as dementia and depression. How are these frailties present and how they should be cared for with a direct link to monitoring findings. Significant changes recorded on the daily monitoring sheets should always be recorded in the care plan to provided clear guidance to staff on how to meet changing needs. The daily records of care seen generally tell the reader what the resident has been doing but not how they feel. They need to give clearer evidence of monitoring residents’ specific care needs. This is especially important where there has been depression, for example. The Manager is aware that records of daily care need to be more informative to comprehensively reflect the service given and is planning to address this by regularly monitoring them and giving staff guidance as necessary. Residents consider they have their health needs well met. References were made to visits by the chiropodist and appointments have been made with optician and audiologist appointments for everyone in the near future. Staff spoken with generally have a good understanding of getting a balance between perceived risks and promoting independence. There have been improvements to the risk assessments, but as with the care plans, further work is required for them to more fully encompass activities undertaken by residents. For example going out independently. The Manager and senior staff are responsible for medication. They have undertaken medication training. There is a designated medical room and a mobile drug trolley. Standards of storage and cleanliness in the medical room are kept to a satisfactory standard within the facilities available. The storage of medicines is much improved since the last key inspection. There is a lockable medicines refrigerator kept in another part of the home to which people have easy access. The Manager undertook to secure the medicines refrigerator as currently it can be picked up and carried away. The Medication Record Administration Record (MAR) sheets inspected are completed appropriately. A count was made of some controlled drugs and these tallied with records. There are now risk assessments for self medicating residents. Medicines were seen to be given in accordance with good practice guidelines. Residents say staff are kind and gentle, this was confirmed by observation and discussion with a visitor. Staff are considerate of the age and dignity of residents and treat them with courtesy. Birchwood House Rest Home DS0000023895.V367354.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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can enjoy a fulfilling lifestyle with good outside links maintained and have as much choice and control over all aspects of their lives as their individual abilities allow. Dietary needs of residents are well catered for with a balanced and varied selection of food that meets their tastes. EVIDENCE: Residents say they are happy with the daily routine of the home and feel it is planned around their individual needs and wishes as far is practicable. Birchwood House encourages residents to take control of their life and be as actively involved in the running of the home as they wish. The atmosphere is comfortable and relaxed. Residents say they have the confidence to discuss and comment where improvements can be made. They say that the owner is generally available to talk with. Mr Patel said he takes residents feedback Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 15 seriously and makes changes where possible, which enables them to enjoy a better quality of life. Activities take place regularly and residents are encouraged to take part as much or as little as they like. An activities co-ordinator regularly visits the home. Residents said they very much enjoy her sessions. The Manager described how she is planning to increase the frequency of outings using a hired minibus and driver. Two outings are already booked for the near future. Residents maintain links with the community through church attendance and visits to and from friends and relatives. Mr Patel said residents are encouraged to take responsibility for their own financial affairs and to use their money as they wish. Where a resident can no longer manage their own money, family or an advocate will be used. Family and friends feel welcome and know they can visit the home at any time. During the inspection a number of visitors were seen in the home and the visitors book records regular visits by families, friends and others. The design of the home provides seating areas within the communal areas of the home where residents can entertain their visitors, in addition to the privacy of their own room. With advance notice, visitors are welcome to stay for lunch. Residents can choose to bring personal effects with them on admission to the home and are encouraged to keep personal items that are important to them in their own room. An experienced cook, of whom residents and staff speak highly, provides good quality meals. An alternative main meal is always available. Residents say they enjoy the food and look forward to mealtimes. Breakfast is taken to residents’ bedrooms and lunch and supper are in the dining room. Residents are able to eat in their own room if they prefer. Mealtimes are generally relaxed; staff are patient and helpful and allow residents the time they need to finish their meal comfortably. Regular drinks and snacks are available. Birchwood House Rest Home DS0000023895.V367354.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents consider their complaints are listened to and acted on. There are systems to protect residents from abuse. EVIDENCE: Residents state they feel safe and well supported and are satisfied with life at the home. The complaints procedure is readily available. Residents say they feel confident that they would be listened to and any necessary action would be taken. The home keeps a record is of all complaints received by them. The Manager said there have not been any complaints received by the home since she took post. The Commission has not received any formal complaints about the home in that time. There are procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. The staff spoken with have a sound understanding of safeguarding adults’ procedures. The Manager Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 17 has arranged for staff to undertake POVA training. There are not any current safeguarding adults alerts in respect of the home. Birchwood House Rest Home DS0000023895.V367354.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): 19, 21, 22 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ safety and quality of life would be enhanced by improvements to the environment in which they live. EVIDENCE: Birchwood House is a grand building with some imposing rooms set within extensive grounds in a rural area. Residents say they find it a comfortable place in which to live. It has been used as a care home for many years with various additions being made. All floors are served by a shaft lift except for the annexe, which is accessed via a stair-lift. The lift was not working at the time of inspection, as there had been a small electrical fire the previous day. Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 19 This clearly inconvenienced some residents with mobility difficulties and the owner was trying to get the lift working again as soon as possible. The garden is large and residents enjoy using it in more clement weather. Manager described how it is planned to provide ramped access to some parts. The steps leading from the patio to the garden have a handrail on one side only. This does not take account of people being right or left-handed. Mr Patel said he would fit additional handrails for residents’ safety. Although it is said there is an ongoing programme of redecoration and refurbishment, the décor in many parts of the home look tired or worn. The last two inspection reports have recommended the worn carpets be replaced. This has still not been done and they have deteriorated further so as to become a trip hazard in some areas. Accordingly, a requirement is made that they are repaired or replaced where necessary. Staff say the bathing and toilet facilities are adequate. Those seen are left free from unnecessary obstruction to allow residents easy access to them and to maintain infection control. A support frame around the toilet in the first floor bathroom is not secured, posing a potential hazard for residents. The Manager undertook to have the frame secured. The laundry room is small and it is difficult to effectively separate soiled and clean laundry. The laundry room is being much better maintained with more effective cleaning, damaged work surfaces have been repaired and shelving removed from inappropriate areas. Foot-pedal operated waste bins are being used in high infection risk areas. Elsewhere, the parts of the home seen are warm, free from offensive odours and generally clean. Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment processes are robust and offer protection to people living at the Home. Training is available to the staff so they have the skills to meet the needs of the residents. EVIDENCE: Residents speak highly of the staff, saying they are friendly and helpful. Although registered for 38, the home currently has 18 people living there. Residents said the number of staff on duty is enough to meet their needs. The staff rosters seen indicate staffing levels are geared to peak times of activity. They also show the home is still reliant on using agency staff to maintain appropriate staffing levels. It was noted that both staff on Saturday nights are agency. The Manager stated that at least one of these would be a person who has worked at the home on a regular basis. The Manager is currently trying to recruit more permanent staff. People applying to work at the home have to complete an application form, and provide satisfactory POVA and Criminal Records Bureau (CRB) checks as Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 21 well as two references. The files of the most recently recruited staff show that appropriate checks are made prior to them commencing duties. The staff files are much better organised than previously. All staff are have been required to complete the Skills for Care induction programme so the Manager can be sure of their skills base. NVQ training in care is being encouraged. The Manager spoke of ongoing training for staff and a training matrix is used to monitor. This would facilitate easier monitoring if it included the actual dates of the training. There has been a lot of training arranged for staff in recent months. This includes Medication, Health and Safety, First Aid, Fire Safety, POVA, Dementia and Challenging Behaviour. As one staff member said “I don’t think I have ever had to do so much training!” Another said “It gives me much more confidence in doing the job”. Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from the recent appointment of a manager and implementation of improved management systems. EVIDENCE: At the time of inspection, the Manager had been in post for eleven weeks. She has extensive experience in residential care and hospital settings. She was previously the registered Manager at another home and has worked with people with dementia for four years. The Manager has acquired the Registered Managers Award, NVQ level 4 in care and is about to commence NVQ level 5. Application for her registration as Manager is to be made in the near future. Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 23 The Management team structure has been augmented by the appointment of a Deputy Manager and a part-time Administrator. A lot of progress has been made in a short time. Care plans, staff training, staff supervision, policies and procedures and documentation have been improved. The next hurdle for the home is to ensure this is consistently translated into good daily practice by all staff. The Manager is monitoring the quality of records made by staff with the aim of achieving a high level of consistency. The need for this is demonstrated by an accident report seen that does not indicate good practice and, the Manager said, is not an accurate portrayal of events. An example of very poor practice in keeping hazardous substances secure was observed. The Manager said she would take immediate action in regard to this. This negated the need to issue Immediate Requirement Notices. People who use the service are invited to comment on the quality of the provision made for them using questionnaires. These should be amended to include space for free text. The Manager said regular residents’ meetings are now being held and it is planned to have relatives’ meetings. Mr Patel stated the home does not act as appointee for any resident. They do support one resident with personal spending. Residents and/or their relatives have not expressed concerns in regard to the holding of cash on their behalf. The Manager said improved environmental risk assessments are to be undertaken on a regular basis. Staff spoken with have a sound understanding of emergency procedures. Mr Patel stated that all records of maintenance and safety checks are up to date. These were not inspected on this occasion. Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 2 X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 2 2 Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 14(2)(b), 15(2), 17 Schedule 3, Schedule 4 Requirement The registered person shall maintain records as specified in Schedules 3 and 4. The registered person shall keep the service user’s plan under review in that service users’ individual plans and records must be more comprehensive and specific in detail of information required. It is acknowledged good progress has been made. All service users must have a comprehensive care plan by the given timescale, if not sooner, which is thereafter maintained. 2. OP7 13(4) The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated in that risk assessments must be more comprehensive to more fully encompass activities undertaken by residents and be recorded in response to incidents and changes in residents welfare. It is acknowledged good Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 26 Timescale for action 31/10/08 31/10/08 progress has been made. Comprehensive risk assessments must be in place by the given timescale, if not sooner, and maintained thereafter. 3. OP19 13(4) The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety in that where worn and damaged carpeting is a trip hazard, it must be replaced or made good. To be completed by the given timescale, if not sooner and maintained thereafter. The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety in that support frames around toilets must be secured. To be completed by the given timescale, if not sooner and maintained thereafter. 30/09/08 4. OP22 13(4) 30/08/08 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. 2. Refer to Standard OP7 OP9 Good Practice Recommendations It is strongly recommended daily records of care are more informative and give clearer evidence of monitoring service users’ specific care needs. It is strongly recommended secure the lockable medicines refrigerator is secured as intended. DS0000023895.V367354.R01.S.doc Version 5.2 Page 27 Birchwood House Rest Home 3. 4. OP26 OP26 It is again strongly recommended improved laundry facilities are provided to better enable a separation of clean and soiled items. It is again strongly recommended improved laundry facilities are provided to better enable a separation of clean and soiled items. It is strongly recommended the home recruit more permanent staff to minimise the frequency it uses agency staff. It is recommended the quality assurance questionnaire is developed to include space for free text. 5. 6. OP27 OP33 Birchwood House Rest Home DS0000023895.V367354.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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