Inspection on 27/11/07 for Birchwood House Rest Home

This inspection was carried out on 27th November 2007.

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

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

Other inspections for this house

Birchwood House Rest Home 22/07/08

Birchwood House Rest Home 03/03/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Birchwood House Rest Home Stockland Green Road Speldhurst Tunbridge Wells Kent TN3 0TU Lead Inspector Gary Bartlett Key Unannounced Inspection 27th November 2007 07:30 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.V353799.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.V353799.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.V353799.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 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 £236 (local authority shared room) to £700.00 per week. Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in Birchwood House from 7:30 a.m. until 4:00 pm. During that time the Inspector spoke with the owner Mr Patel, some residents, 2 visitors, some staff and the visiting activities person. Parts of the home and some records were inspected and care practices observed. All staff gave their full co-operation throughout the inspection. 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. What the service does well: Residents say they enjoy living at Birchwood House and are very happy here. The home provides a comfortable environment and the standard of cleanliness is good. There is an open and friendly atmosphere with good communication between residents, staff and visitors. There is encouragement for residents to partake in activities suited to their preferences and capabilities. Residents enjoy the meals. Staff are good at helping new residents to settle in. Staff recruitment process are robust to ensure only appropriate people work at the home. Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Birchwood House Rest Home DS0000023895.V353799.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.V353799.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. 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: Mr Patel 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. He 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.V353799.R01.S.doc Version 5.2 Page 9 Residents said they or their families had been able to visit Birchwood House 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.V353799.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. 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. Records of care must be more consistently maintained to reflect the quality of care given. More consistent adherence to guidelines for the storage and administration of medicines would better protect residents. Residents’ health needs were met with good liaison with relevant health care professionals. Staff treat residents with respect and maintain their privacy and dignity. EVIDENCE: Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 11 Each resident has a care plan and three were inspected in detail. As one senior carer said “they are a bit of a mess”. They need to be more comprehensive with information about residents’ needs and capabilities readily available to staff. The care plans must be clearly directive so staff know how to meet residents’ care needs. Current daily records of care are not kept with the care plans so staff do not have ready access to them when recording information. A newly appointed Team Leader is aware that some records of daily care need to be more informative to comprehensively reflect the service given and is planning to address this by regularly reviewing them and giving staff guidance as necessary. The daily records of care are not kept securely when not in use, thereby potentially compromising confidentiality. Staff spoken with have a good understanding of getting a balance between perceived risks and promoting independence. However, the risk assessments recorded in the care plans 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. It is evident from records seen and discussion with residents and staff that residents have ready access to health care professionals as necessary. An optician was visiting on the day of inspection. Comments made by residents during discussion included: • “Since moving here, I have felt much better and stronger than I have done for a long time”. • “They look after you very well here”. • “It is absolutely wonderful, nothing is too much trouble”. There is currently not a key worker system because of recent changes in staff personnel. A senior staff member acknowledges such a system would contribute to an improved exchange of information about residents’ health and welfare. It is intended to reintroduce a key worker system when a new manager is appointed. Medicines were seen to be given in accordance with good practice guidelines at lunchtime. The rooms used for the storage of medicines are adequately maintained but there are not systems in place to ensure all medicines are stored at an appropraite temperature. Medicines are only administered by staff who have been trained to do so but there is not an up to date list of these people with speciman signatures. Some of the Medication Record Administration Record (MAR) sheets inspected contained gaps that could not be readily explained. Most MAR sheets are computer generated by the pharmacist but some are hand written. These must be must be signed by the person completing them and countersigned by a second person checking their accuracy. The owner undertook to address these matters to lessen the potential risk to residents. Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 12 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: A resident said “I am allowed to do as I like here, if I don’t want to get up, I don’t have to”. Discussion with residents and staff show that the routines of the home are planned around the residents’ individual needs and wishes. Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 13 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 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. A visiting activities co-ordinator was at the home during the afternoon of the inspection. Residents said they very much enjoy her regular attendance. Residents maintain links with the community through church attendance and visits to and from friends and relatives. 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. 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. 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. Food and mealtimes are treated as an occasion and something to be looked forward to. Breakfast is taken to residents’ bedrooms and lunch and supper in the dining room. Residents are able to eat in their own room if they prefer. An experienced cook, of whom residents and staff spoke highly, provides good quality meals that meet the dietary needs of the residents. An alternative meal is always offered. Mealtimes are 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.V353799.R01.S.doc Version 5.2 Page 14 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 and their relatives know their complaints are listened to and acted on. There are systems to protect residents from abuse. EVIDENCE: Residents and relatives state they are very satisfied with the service provision, feel safe and well supported by owner who has their welfare as a priority. The complaints procedure is readily available. Residents say they feel confident that they would be listened to and any necessary action would be taken. Residents said: • “Here, if you have any problems, no matter how small, you can mention it and it will be dealt with quickly”. • “I can’t think there is anything to complain about”. Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 15 The Home keeps a record is of all complaints received by them. These indicate there have been 2 complaints received by the home in the last 12 months. One was upheld and both were resolved within an appropriate timescale. 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 owner and staff spoken with have a sound understanding of safeguarding adults’ procedures. During the last year, there has been one safeguarding adults alert raised, which is currently being investigated. Birchwood House Rest Home DS0000023895.V353799.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Birchwood House is a comfortable home. Improvements to the laundry and some staff practices would maintain infection control better. EVIDENCE: Birchwood House is a large building set within extensive grounds in a rural area. 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 home has car parking to the front of the house. Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 17 The garden is large and residents enjoy using it in more clement weather. The lounge, dining room and conservatory provide a good outlook over the garden at all times of year. There is an ongoing programme of redecoration and refurbishment. The owner is intending to replace the lounge carpet where it has become worn and is a potential trip hazard. Some rooms have been redecorated since the last inspection and some windows replaced. The conservatory is currently being redecorated. Residents say they find Birchwood House to be a comfortable place in which to live. It is a grand building with some imposing rooms. The effect is somewhat diminished by the untidy appearance of some notices. The environment would be more homely if staff were more vigilant in putting items such as laundry and equipment away. Staff must also be better at following instructions with regard to leaving items in bathrooms/toilets to allow residents easy access to these facilities and to maintain infection control. Laundry practices must be improved to promote infection control. There are not systems for effectively separating soiled and clean laundry. The laundry room must be better maintained with more effective cleaning and the replacement of damaged work surfaces. High infection risk areas should be provided with foot-pedal operated waste bins. Elsewhere, the home is warm, clean and free from offensive odours. Birchwood House Rest Home DS0000023895.V353799.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents feel there are adequate numbers of staff on duty and that the staff are caring people. EVIDENCE: Resident’s comments during the inspection included: • “They are very caring and willing to help”. • “The staff here are lovely”. Resident’s and visitors speak highly of the care staff, saying they are friendly and helpful. The staff rosters seen indicate staffing levels are geared to peak times of activity. People applying to work at the home have to complete an application form, attend an interview, provide references and satisfactory POVA and CRB checks. The application form needs to be updated to provide all of the information required by Regulations and to comply with current employment legislation. Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 19 The files of the most recently recruited staff show that appropriate checks are made prior to them commencing duties. New staff are required to undertake an in-house induction programme. Mr Patel said he is seeking advice about a new induction programme that will meet the criteria requirements highlighted on the Skills for Care website. Agency staff are given an induction when they first work at the home but it is not recorded. Mr Patel undertook to ensure a record is kept of agency staff induction. It was established at the last inspection that there was ongoing training for staff. The manager then in post maintained a training matrix to monitor individual staff members’ training requirements. Since that Manager has left, the training matrix has disappeared. Consequently it is difficult to assess the current situation. Mr Patel agreed to undertake a training-needs analysis for every staff member. Birchwood House Rest Home DS0000023895.V353799.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The absence of an experienced and qualified manager is having a detrimental effect on the safe and efficient running of the home. EVIDENCE: Birchwood House is presently without a manager, the last manager having unexpectedly left at very short notice having been in post for a brief time. A Team Leader is temporarily acting up. The senior staff has been bolstered by the recent appointment of a knowledgable and experienced Team Leader who is due to take post in the near future. Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 21 Staff supervision is an obvious casuality to there not being a manager in post. Until a new manager is appointed, Mr Patel is going to be in attendance at the home most days of the week. The necessity of this is demonstrated by staff not adhering to COSHH requirements or following advisory notices. Examples being; their failure to secure cleaning chemicals when not in use, to not obstruct residents’ access to toilets, the leaving of clean laundry next to toilets and the poor maintenance of MAR sheets. All of which place residents at potential risk. People who use the service are invited informally to comment on the adequacy of the provision made for them and Mr Patel said there had been some use of questionnaires and residents meetings in the past. The arrangements need to be developed to be confident that that everyone who wants to have their say has been given the opportunity to do so. These methods should be designed specifically around the individual needs and abilities of each resident with regard being given to independent advocacy. 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. Daily records of care are kept on a shelf in a throughway. Staff use this area so the records are conveniently sited for them but it idoes not provide secure storage when they are not in use. Therefore, confidentiality can not be assured. Speaking with staff, it is apparent that some of the policies and procedures displayed in the home are no longer reflective of practices within the home. These must be updated to avoid confusion and to ensure they comply with current legislation and good practice guidance. As mentioned earlier in this report, the staff application form needs to be updated so the home has all information about each staff member required by Regulations. There was some discussion about the improved safeguards of having recorded environmental risk assessments 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.V353799.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 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 2 3 2 X X 3 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 1 2 2 Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 23 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 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 kept and be up to date in that they must be consistent and specific in detail of information required. All service users must have an accurate care plan by the given timescale, if not sooner, which is thereafter maintained 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 and recorded in response to incidents and changes in residents welfare. Comprehensive risk assessments must be in place by the given timescale, if not sooner, and maintained thereafter. “The registered person shall make arrangements for the DS0000023895.V353799.R01.S.doc Timescale for action 31/03/08 2. OP7 13(4) 31/03/08 3. OP9 13(2) 31/12/07 Page 24 Birchwood House Rest Home Version 5.2 recording, handling, safekeeping, safe administration of medicines” in that: 1. Systems must be in place to ensure all medicines are stored at an appropraite temperature. 2. There must be in the home an up to date list of staff who have received training in the administration of medication and who are authorised to administer medication in this home. 3. Hand written Medicine Administration Charts must be signed by the person completing them and countersigned by a second person checking their accuracy. 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 resident’s’ bathrooms/toilets are free of stored items of equipment at all times. To be completed by the given timescale, if not sooner and maintained thereafter. The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home, in that: 1. The laundry must be kept clean and well maintained. 2. Laundry procedures must ensure a separation of DS0000023895.V353799.R01.S.doc 4. OP22 13(4) 31/12/07 5. OP26 12(1), 13(3)(4) (c) 16(2)(j) 31/12/07 Birchwood House Rest Home Version 5.2 Page 25 clean and soiled items. This must include the storage of clean laundry. 3. Foot-pedal operated bins must be provided in areas of high risk of infection. To be completed by the given timescale, if not sooner and maintained thereafter. “The registered person shall, having regard to the size of the care home, the statement of purpose and numbers and needs of service users ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform including structured induction training” in that the home must be able to produce evidence of an induction programme undertaken by agency staff at their first shift at the home. To be completed by the given timescale, if not sooner and maintained thereafter. “The registered person shall, having regard to the size of the care home, the statement of purpose and numbers and needs of service users ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform including structured induction training” in that a detailed training analysis must be made for every staff member that includes: 1. Training they have undertaken 2. Training courses booked 3. Details of training provider DS0000023895.V353799.R01.S.doc 6. OP30 18(1)(c) 31/01/08 7. OP30 18(1)(c) 31/01/08 Birchwood House Rest Home Version 5.2 Page 26 8. OP31 8(1) 9 and any accreditation they may have. A copy of this must be received by CSCI by the given timescale “The registered provider shall appoint an individual to manage the care home” To be completed by the given timescale, if not sooner. Staff records must comply with Schedules 2 and 4. To be completed by the given timescale, if not sooner and maintained thereafter. “The registered person shall make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users”, in that records of care must be stored securely when not in use. To be completed by the given timescale, if not sooner and maintained thereafter. “The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users” in that all policies and procedures must comply with current legislation and good practice guidance and be reflective of practices within the home. To be completed by the given timescale, if not sooner and maintained thereafter. 31/03/08 9. OP37 17(2) 19 31/03/08 10. OP37 12(4)(a) 31/12/07 11. OP38 12(1)(a) 31/03/08 Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 27 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. 3. 4. Refer to Standard OP7 Good Practice Recommendations It is strongly recommended the care plans and daily records of care are kept in such a manner that they can be readily referred to and cross-referenced. It is strongly recommended the threadbare carpeting in the lounge is replaced. It is recommended effective quality assurance and monitoring systems based on a systematic cycle of planning-action-review are introduced It is recommended recorded environmental risk assessments be undertaken more frequently and that staff be trained in this. OP19 OP33 OP38 Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local 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. Extracts may not be used or reproduced without the express permission of CSCI Birchwood House Rest Home DS0000023895.V353799.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!