Inspection on 03/03/08 for Birchwood House Rest Home

This inspection was carried out on 3rd March 2008.

CSCI found this care home to be providing an Poor 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 22/07/08

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 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 3rd March 2008 11:55 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.V359171.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.V359171.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 vacant post 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.V359171.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th November 2007 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.V359171.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 0 stars. This means the people who use this service experience poor quality outcomes. This key unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in Birchwood House from 11:55 a.m. until 5:05 pm. During that time the Inspector spoke with the owner Mr Patel, some residents and some staff. 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 some 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.V359171.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: It is essential that an experienced and qualified manager is appointed at the soonest possible moment. Residents’ health and welfare would be better promoted if the care plans are further improved to be clearer, more directive and risk assessments are more comprehensive. The current arrangements for the storage of medicines could place residents at risk. Improved laundry facilities would better enable a separation of clean and soiled items. Worn and threadbare carpeting should be replaced before they become a hazard. Birchwood House Rest Home DS0000023895.V359171.R01.S.doc Version 5.2 Page 7 Effective quality assurance and monitoring systems based on a systematic cycle of planning-action-review should be introduced. Recorded environmental risk assessments should be undertaken more frequently and staff be trained to do this. Formal staff supervision should be implemented as soon as is practicable. 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.V359171.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birchwood House Rest Home DS0000023895.V359171.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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: There has been one admission to Birchwood House since the last inspection. A pre-admission assessment is made of each prospective resident. The assessment process includes visiting the resident in their home or in hospital when possible and recording the findings of the assessment, the detail of which then informs the initial care plan. Mr Patel said prospective residents, their families, advocates, and relevant health care professionals are involved in the Birchwood House Rest Home DS0000023895.V359171.R01.S.doc Version 5.2 Page 10 assessment process. Specialist advice is sought from external sources where required. 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.V359171.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The quality of care offered to service users is compromised because care plans and records of care are not consistently maintained to reflect the quality of care given. The current arrangements for the storage of medicines could place residents at risk. The home liaises with health care professionals to meet residents’ health needs. Staff treat residents with respect and maintain their privacy and dignity. EVIDENCE: Birchwood House Rest Home DS0000023895.V359171.R01.S.doc Version 5.2 Page 12 Each resident has a care plan and three were inspected in detail. A lot of work has been done to make them more comprehensive with information about residents’ needs and capabilities readily available to staff. More work is still to be done. For example, a resident was seen to transfer from a wheelchair with the help of one carer, although the care plan states transfers are to be done with the assistance of two carers. Staff explained that two carers are only needed at certain times depending on the resident’s mood. The care plan must reflect this. Current daily records of care are now integral with the care plans so staff have ready access to the plans when recording information and are kept securely when not in use, thereby promoting confidentiality. Staff spoken with have a good understanding of getting a balance between perceived risks and promoting independence. There have been some improvements to the risk assessments, but as with the care plans, further work is required for them to be 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. There is currently not a key worker system. Mr Patel acknowledges such a system would contribute to an improved exchange of information about residents’ health and welfare. It has been difficult to implement this as there has been a change in staffing personnel in recent months. Mr Patel intends to reintroduce a key worker system when a new manager is appointed. The home has recently adopted a blister pack system for residents’ medications. The Medication Administration Records seen indicate that residents receive their prescribed medication. An up to date list of staff authorised to give medication is in place. Although training on the new blister pack system has been arranged to take place in the near future, the senior staff member spoken with has not had recent training on medicine management. Storage of medicines is unsafe as some medicines are not kept secure. The storage of medicines must be orderly and minimise the risk of an error in administration of a medicine being made. A recent change in the law means that all care homes must now keep all Controlled Drugs, including Temazepam, in a Controlled Drugs cupboard that complies with the Misuse of Drugs (Safe Custody) Regulations 1973. The arrangements in the home do not currently comply with this. Eye drops had not been dated when opened. The date of opening medicines must be recorded to avoid the risk of using them when time-expired. One of Birchwood House Rest Home DS0000023895.V359171.R01.S.doc Version 5.2 Page 13 the two medicines rooms is also used for storage of items which should be stopped as this entails unnecessary access to the area. Although there is choice around self-administration of medicine, there is no documentation on risk assessments for this process. Birchwood House Rest Home DS0000023895.V359171.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 they are planned around their individual needs and wishes. 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 Birchwood House Rest Home DS0000023895.V359171.R01.S.doc Version 5.2 Page 15 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. An experienced cook, of whom residents and staff speak highly, provides good quality meals that meet the dietary needs of the residents. An alternative meal is always offered. The cook prefers to do “real” cooking and baking, which is appreciated by the residents. They 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 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.V359171.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 are very satisfied with the service provision, feel safe and well supported. 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. These indicate there have not been any complaints received by the home since the last inspection. 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 Birchwood House Rest Home DS0000023895.V359171.R01.S.doc Version 5.2 Page 17 spoken with have a sound understanding of safeguarding adults’ procedures. Mr Patel is aware of the need to ensure the recently recruited staff receive training as soon as possible. During the last year, there has been one safeguarding adults alert raised, which has been closed in respect of that individual. Birchwood House Rest Home DS0000023895.V359171.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 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. Residents’ quality of life would be enhanced by some 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 home has car parking to the front of the house. Birchwood House Rest Home DS0000023895.V359171.R01.S.doc Version 5.2 Page 19 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 still to replace the lounge carpet where it has become worn and is a potential trip hazard. Other carpets are beginning to look frayed and worn. The conservatory is currently being redecorated. Staff say the bathing and toilet facilities are adequate. They are left free from unnecessary obstruction to allow residents easy access to these facilities and to maintain infection control. The laundry room is small and it is difficult to effectively separate soiled and clean laundry. The laundry room is being better maintained with more effective cleaning and damaged work surfaces have been repaired. Foot-pedal operated waste bins have been ordered for use 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.V359171.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 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: The staffing of Birchwood House has been very unsettled in recent months. There is still not a Manager, a Team Leader appointed in December left after a short while and a senior carer has recently resigned. There have also been changes in the night staff. Two new care staff have been appointed, these are currently having induction and require daily supervision as they do not have previous experience of residential care work. Residents 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. Mr Patel considers the staffing levels are adequate for the number of people currently living at the home. Residents say that staff are generally available when needed. Mr Patel is aware that staffing levels will have to be adjusted accordingly if there are further admissions to the home or an increase in current residents’ care needs. Birchwood House Rest Home DS0000023895.V359171.R01.S.doc Version 5.2 Page 21 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 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. A new induction programme, Common Induction Standards for Social Care” has been introduced recently. Agency staff are given an induction when they first work at the home and, in response to a requirement made in the last inspection report, Mr Patel is in the process of implementing a system for recording this. Since the last inspection, Mr Patel has arranged for the South East Care Advice Service to visit the home and do a skills audit for each staff member and to provide resultant individual development plans. Some training courses have been arranged for staff, which includes dementia, POVA, infection control, fire safety, manual handling, emergency first aid, food hygiene and medication training. Birchwood House Rest Home DS0000023895.V359171.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 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 in October 2007, at very short notice having been in post for a brief time. Mr Patel is in attendance at the home more frequently and a Team Leader is temporarily acting up. The senior staff has been further Birchwood House Rest Home DS0000023895.V359171.R01.S.doc Version 5.2 Page 23 denuded by the leaving of a Team Leader and senior carer. In response to the last inspection report, Mr Patel has commissioned the registered Manager of a care home to act as a consultant. He had appointed a person to be Manager and to take post in the near future, but this person has recently decided to go abroad. Consequently, Mr Patel has to go through the recruitment process again. As an interim measure he has approached an agency to provide management support. In addition to this, there have been personal circumstances that have prevented Mr Patel from addressing the requirements made in the last inspection report as fully as he would have liked. Staff supervision is an obvious casuality to there not being a manager in post. There are not the resources for formal supervision currently, and staff supervision is having to be done on a basis of daily observation. For example, staff are sometimes needing to be reminded to maintain infection control in the laundry and food hygiene requirements in the kitchen. 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. As discussed at the previous inspection, 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 now kept with the care plans in the office when they are not in use to maintain confidentiality. Mr Patel has recently acquired a new set of policies and procedures that comply with current legislation and good practice guidelines. He intends to have these personalised for the purposes of the home. 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.V359171.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 3 9 X 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 X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 2 2 2 Birchwood House Rest Home DS0000023895.V359171.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 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. A previous timescale of 31/03/08 was given. There is progress being made. The timescale has been extended in acknowledgement of this and of the difficulties experienced in recruiting a Manager. The registered person shall 30/08/08 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 DS0000023895.V359171.R01.S.doc Version 5.2 Page 26 Timescale for action 30/08/08 2. OP7 13(4) Birchwood House Rest Home 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. A previous timescale of 31/03/08 was given. There is progress being made. The timescale has been extended in acknowledgement of this and of the difficulties experienced in recruiting a Manager. 3. OP9 13(2) “The registered person shall 16/05/08 make arrangements for the recording, handling, safekeeping, safe administration of medicines” in that a Controlled Drugs cupboard complying with the Misuse of Drugs (Safe Custody) Regulations 1973 must be obtained. All Controlled Drugs, including Temazepam must be stored in the Controlled Drugs cupboard. To be completed by the given timescale, if not sooner and maintained thereafter. 30/04/08 “The registered person shall make arrangements for the recording, handling, safekeeping, safe administration of medicines” in that a documented risk assessment must be in place for all service users who undertake to self-administer their own medication. To be completed by the given timescale, if not sooner and maintained thereafter. “The registered person shall DS0000023895.V359171.R01.S.doc 4. OP9 13(2) 5. OP9 13(2) 30/04/08 Page 27 Birchwood House Rest Home Version 5.2 6. OP31 8(1)9 make arrangements for the recording, handling, safekeeping, safe administration of medicines” in that: 1. The storage of medicines must be orderly and minimise the risk of an error in administration of a medicine being made. 2. The date of opening medicines must be recorded to avoid the risk of using them when timeexpired. The registered provider shall 30/06/08 appoint an individual to manage the care home To be completed by the given timescale, if not sooner. A previous timescale of 31/03/08 was given. The timescale has been extended in acknowledgement of the difficulties experienced in recruiting a Manager. 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 OP9 OP19 Good Practice Recommendations It is strongly recommended the medicines rooms are not used for the storage of general items of equipment. It is strongly recommended worn and threadbare carpeting is replaced. This recommendation remains outstanding from the previous inspection report. It is strongly recommended improved laundry facilities are provided to better enable a separation of clean and soiled items. DS0000023895.V359171.R01.S.doc Version 5.2 Page 28 3. OP26 Birchwood House Rest Home 4. OP33 5. 6. OP36 OP38 It is recommended effective quality assurance and monitoring systems based on a systematic cycle of planning-action-review are introduced This recommendation remains outstanding from the previous inspection report. It is strongly recommended formal staff supervision is implemented as soon as is practicable. It is recommended recorded environmental risk assessments be undertaken more frequently and that staff be trained in this. This recommendation remains outstanding from the previous inspection report. Birchwood House Rest Home DS0000023895.V359171.R01.S.doc Version 5.2 Page 29 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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