Inspection on 22/05/07 for Birdhurst Gardens

This inspection was carried out on 22nd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birdhurst Gardens 09/05/06

Birdhurst Gardens 21/11/05

Birdhurst Gardens 31/05/05

Birdhurst Gardens 26/07/04

Birdhurst Gardens 26/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Birdhurst Gardens 15 Birdhurst Gardens South Croydon Surrey CR2 7DT Lead Inspector James O`Hara Key Unannounced Inspection 22nd May 2007 08:45 Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 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 Birdhurst Gardens DS0000025755.V340019.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 Adults 18-65. 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. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birdhurst Gardens Address 15 Birdhurst Gardens South Croydon Surrey CR2 7DT 020 8680 6876 020 8681 1649 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) Surrey and Borders Partnership NHS Trust Ms Sarah Sowambur Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: Birdhurst Gardens is registered to provide care for up to nine adults with learning disabilities. There are currently seven service users living at the home. The home also provides respite care to four service users. Birdhurst Gardens is situated in a quite residential street of similar properties in south Croydon. The home is a large detached property built over three floors. Each of the service users has a single bedroom; there is also a communal lounge/dining room as well as, bathrooms, an office and kitchen. To the rear of the premises is a pleasant garden, which is well used in the summer months. The home has an outside laundry facility and parking to the front. All service users are charged a fee of £57, 898, 09 per annum. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was carried out between 8.45am and 12.30pm on a Tuesday morning/afternoon. Methods of inspection included a tour of the premises, observation of contact between staff and people who use the service and discussion with Ms Sowambur, the registered manager. Records examined included person centred plans, risk assessments, complaints, adult protection, staffing training records, Statement of Purpose, Service Users Guide, medication, and health and safety records. Requirements and recommendations from the previous inspection were also discussed Ms Sowambur. A random unannounced inspection took place at the home on the 24th of January 2007. This report includes information from that inspection. What the service does well: What has improved since the last inspection? All of the people who use the service have had their needs assessed by their care managers. All staff attended training on Person Centred Planning in 2006. People now have a Person Centred Plan. The level of personal care support people need and their preferred routines are recorded in the person centred plan. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 6 The home is working towards improving communication, each person has a communication dictionary, a document designed to support people who do not use words to talk or have difficulty in communicating with words. The homes procedures for the recruitment of staff provide the necessary safeguards to ensure that so far as reasonably practicable people are not placed at risk of harm or abuse. The home has had a new kitchen fitted. Weekly fire alarm checks are now carried out. What they could do better: There were a total of eight requirements and four recommendations set at the last key inspection. All of the requirements and recommendations were assessed as met at the random unannounced visit to the home on the 24th of January 2007. One requirement was set at that inspection; this requirement has also been met. As a result of this inspection there is one requirement and five recommendations. The overall impression when visiting the home is that it is well managed however there were a number of shortfalls identified, most of the shortfalls related to personal healthcare and support. Generally people can be assured that they receive support in the way they prefer and require however the home needs to make sure that all staff is aware of the home’s policies and procedures for handling medicines. The manager could carry out weekly medication checks to make sure that people are receiving their prescribed medication. Staff would benefit from refresher training on diabetes. The specialist diabetic nurse could confirm in writing that staff is competent to administer insulin. Where people need support with personal care tasks such as bathing, brushing teeth and shaving etc more detail and instruction could be recorded so that unfamiliar staff are aware of exactly how that person should be supported. Staff would benefit from refresher training on adult protection. So that the diverse needs of people who use the service are considered, care plans and person centred plans could include reference to how the service will meet their needs and preferences in relation to race, religion, gender, sexual orientation, age and disability. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 7 The inspector would like to thank the people who use the service and their relatives, the staff and Ms Sowambur for their support in the inspection process. 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. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides people who plan to use the service and their representatives with the information they need so that they can make an informed decision about whether or not to use the service. The homes admission procedure ensures that people would have a thorough assessment of their needs and aspirations before they move in. EVIDENCE: The home has a Statement of Purpose and Service Users Guide. Information included in these documents reflects what is required in the Care Home Regulations. The registered manager, Ms Sarah Sowambur, stated that no new people have moved into the home since the last inspection. Ms Sowambur stated that the home would employ the Surrey and Borders NHS Trusts Admission Procedure if she were to admit any new people. The procedure states that people are only admitted to the home once a full assessment has been completed by an appropriate person (usually a care manager) and sent to the home, along with any other information about their Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 10 needs. The family of people who wish to use the service is also involved, if it is appropriate. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have comprehensive care plans and person centred plans that include information on their needs and personal goals. They have individual risk assessments and risk management strategies in place so that they can participate in activities in the home and in the community in a safe manner. EVIDENCE: A requirement was set at the last key inspection, 9th May 2006, that the registered manager contact all of the people who use the service care managers and make arrangements for their assessed needs to be kept under review. Evidence of reviews must be available in the home for inspection. At a random unannounced inspection on the 21st of January 2007 Mrs Sowambur, produced evidence that all of the people who use the service have had their needs assessed by their care managers. Peoples updated assessed needs are now kept on file. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 12 A requirement was set at the last key inspection that the registered manager ensures that the level of personal care support people need and their preferred routines are recorded in the Person Centred Plans. At the random unannounced inspection Mrs Sowambur, produced evidence that all staff had attended training on Person Centred Planning in 2006. All of the people who use the service had a Person Centred Plan. Mrs Sowambur produced evidence that the level of personal care support people needed and their preferred routines were now recorded in the Person Centred Plans. During this visit it was noted that one persons centred plan stated that the person needed support with brushing their teeth but the plan did not indicate how this support should be offered. Ms Sowambur agreed that a member of staff not familiar with the persons needs could be confused as to how this task should be completed. It is recommended that where people need support with personal care tasks such as bathing, brushing teeth and shaving etc more detail and instruction should be recorded so that unfamiliar staff are aware of exactly how that person should be supported. During this visit three peoples personal files were sampled. All of the files included a service user profile, a person centred plan, a communication dictionary, residents survey, relatives survey, Service Users Guide, weekly activities timetable, a health action plan, a care plan from the placing authority and completed up to date risk assessments. The communication dictionary is a document designed to support people who do not use words to talk or have difficulty in communicating with words. One completed document described how the person communicated that they were bored, hungry, thirsty, sad/upset, in pain, angry or wanted to go out. Files sampled had risk assessments/risk management strategies in place so that people could participate in activities in the home and in the community in a safe manner. These had been reviewed on a regular basis. Ms Sowambur agreed that the Person Centred Plans were in the early stages of development and that more would be done to evidence that people who use the service have contributed to their plans. Ms Sowambur explained her plans for people to take pictures and use cue/prompt boxes in the person centred planning process. It was agreed that the plans contained good information and with further development this could lead to the home achieving an excellent quality outcome in this area at future inspections. The subject of Equality and Diversity was discussed in relation to information recorded in person centred plans. There appeared to be little reference to Equality and Diversity. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 13 So that the diverse needs of people who use the service are considered, care plans and person centred plans could include reference to how the service will meet their needs and preferences in relation to race, religion, gender, sexual orientation, age and disability. Ms Sowambur produced minutes from residents meetings for January and February 2007. These had been completed in words and pictures and included peoples comments and opinions about the service and their wishes for activities, holidays and choice of food etc. The home also completed a “Birdhirst Gardens Newsletter” that included a summary of activities attended by people throughout 2006. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to attend appropriate social activities so that they can become part of the local community. Appropriate arrangements are made so that people have regular contact with their friends and families. Dietary needs are well catered for and well-balanced, nutritional meals, based on personal preferences are being prepared and offered to people who use the service. EVIDENCE: Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 15 People have a varied programme of social activities with an emphasis on using community facilities. They all attend day services at Geoffrey Harris House four days per week. Ms Sowambur stated that people go on different days and now have individual activity timetables, including household activities and recreational activities. People also use the local pub and go into nearby Croydon to restaurants and cafes. One weekly activity plan indicated that the person went shopping, helped to cook, set tables, done the laundry, went to the Monday Club, Bingo, went for walks and went to Church. The persons person centred plan included guidelines on how she should be supported with these activities. Ms Sowambur stated that one person attended college last year and would be applying again in September. This person is registered blind/visually impaired, he attends Croydon Voluntary Association for the Blind on Mondays and Wednesdays when he goes bowling and gets together with other people who are registered blind/visually impaired. Ms Sowambur stated that she planned to support everyone living at the home to apply for suitable college courses in September. Ms Sowambur stated that some people have regular visits to and from family and some keep in contact with relatives and friends by letters or telephone. Ms Sowambur stated that relatives are invited to peoples care plan reviews, Christmas and birthday parties and barbeques in the summer. Food menus are based on a four-week rota and are based on people’s likes and dislikes. Menus seem varied and also include some ethnic option meals. People are offered an alternative to the main meal. These trusts dietician checks the menus for nutrition and balance. The home has made a pictorial menu for some people. People’s weekly activity records indicate that they are supported to prepare and cook meals for themselves and others in the home. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally people can be assured that they receive support in the way they prefer and require and are generally protected by the home’s policies and procedures for handling medicines. EVIDENCE: It was noted that one persons centred plan stated that the person needed support with brushing their teeth but the plan did not indicate how this support should be offered. Ms Sowambur agreed that a member of staff not familiar with the persons needs could be confused as to how this task should be completed. It is recommended that where people need support with personal care tasks such as bathing, brushing teeth and shaving etc more detail and instruction should be recorded so that unfamiliar staff are aware of exactly how that person should be supported. All people who use the service have a health action plan and all had an annual health screen check. There was evidence that people have good access to health care professionals including Opticians, Dentists and Psychologists. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 17 One person has epilepsy; Ms Sowambur produced evidence that all staff attended training on epilepsy on the 12th of June 2006. Ms Sowambur stated that the home offers respite care and support to two people that have diabetes. Ms Sowambur produced evidence that a number of staff attended training on diabetes in early 2005; this training included the administration of insulin. It is recommended that staff receives refresher training on diabetes and that the specialist diabetic nurse confirms in writing that staff are competent to administer insulin to people with diabetes. Medication is stored in a locked cabinet in a small room under the stairs. Medication administration records were examined. It was observed that on two days this month medication had been administered but not signed for. Ms Sowambur was able to identify the member of staff responsible and the actions she would be taking to deal with this issue. The registered manager must ensure that all staff is aware of the home’s policies and procedures for handling medicines so as to ensure that people are so far as reasonably practicable protected from harm. This will be monitored at future inspection visits. It is recommended that the registered manager carry out weekly medication checks to make sure that people are receiving their prescribed medication. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home has an appropriate complaints procedure in a number of formats so that people who use the service can understand. The home has suitable vulnerable adult protection and abuse prevention measures in place so that people are so far as reasonably practicable protected from abuse. EVIDENCE: At the time of writing this report a number of comment cards were returned to the Commission from people who use the service and one relative. Ms Sowambur stated that because of the communication difficulties of some people she and a member of staff had supported people to complete the comment cards. In general feedback was positive. The relative stated that they were never kept up to date with important issues affecting their relative. They also stated that the home looks after people who use the service well but felt that people could get more exercise in the open air. They also stated that the home could do more to inform them of any accidents relating to their relative. Ms Sowambur produced a card from a relative thanking the home for the good care afforded her nephew. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 19 The homes complaints procedure is completed in text and picture (Widget) for the benefit of some people who use the service. Ms Sowambur produced evidence that all members of staff had attended adult protection training in December 2005. It is recommended that all members of staff attend refresher training on adult protection. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The overall impression when visiting this home is that it is well decorated, homely, comfortable, clean and hygienic. EVIDENCE: Requirements were set at the key inspection that the registered manager must make sure that the kitchen drawer with sharp broken edges be repaired or replaced. At the random inspection it was observed that the home had a new kitchen fitted. It was recommended that the registered manager contact the works department to unblock the bath. At the random inspection it was observed that the Surrey and Borders NHS Trust works department had unblocked the bath. It was recommended that the registered manager contact the works department and arrange for the carpet in one persons bedroom to be cleaned. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 21 At the random inspection it was observed that the carpet in this bedroom had been cleaned. The home has a toilet and bathrooms on each floor plus two separate toilets. Bedrooms are of good size and sufficient to meet people’s individual needs and lifestyles. Bedrooms have been decorated to their own personal choices. Furniture is of good quality. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The homes procedures for the recruitment of staff appear to be robust and provide the necessary safeguards to ensure that so far as reasonably practicable people who use the service are not placed at risk of harm or abuse. Staff at the home receives regular supervision so as to ensure that people who use the service benefit from having a consistent approach to their needs. EVIDENCE: A requirement was set at the key inspection that the registered manager contact the Commission when she obtains staff the information as required in Regulation 19 (1) b and Schedule 2 National Minimum Standards and arrange a date for these to be inspected. Another requirement was set that the registered manager contact the Commission when she receives the Criminal Records Bureau Checks for two members of staffs and arrange a date for these to be inspected. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 23 Ms Sowambur contacted the Commission on the 8th of December 2006 in relation to this requirement. During the random inspection Ms Sowambur produced evidence that all of the information as required in Regulation 19 (1) b and Schedule 2 Care Homes Regulations is available for each member of staff. During the random inspection it was observed that one member of staff started work in the home in July 2006. The member of staff had completed the application form on line but had left out important details in relation to their recent employment history and the reasons for leaving their last place of work. Where a person has previously worked in a position that involved contact with vulnerable adults written verification of the reason why they ceased to work in that position must be obtained together with a full employment history and written explanation regarding any gaps in employment. A requirement was set that the registered provider must ensure that application forms are completed to a full and satisfactory standard and any gaps in employment history explored. During this visit Ms Sowambur produced an updated/retrospective employment history recorded held on the member of staffs personnel file. Ms Sowambur stated that she had attended recruitment and selection training on the 2nd of February 2006. Ms Sowambur stated that the training would benefit her in the recruitment and selection process in future. A requirement was set at the key inspection that the registered manager must ensure that all staff has an annual appraisal. During the random inspection Ms Sowambur produced evidence that all staff are undergoing the Surrey and Borders NHS Trusts appraisal system “Knowledge and Skills Framework”. Three staff files sampled included completed “Knowledge and Skills Framework” formats. Staff supervision record where examined and indicated that staff has regular recorded supervisions. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall impression when visiting the home is that it is well managed. There have been a number of improvements made benefiting people who use the service and staff since the last key inspection. EVIDENCE: A requirement was set at the key inspection that the registered manager sends a copy of her NVQ level 4 certificate to the Commission. At the random inspection Ms Sowambur stated that she had completed her NVQ level 4 coursework and is awaiting the certificate from her line manager who is also her NVQ assessor. It was recommended that Ms Sowambur send a copy of her NVQ level 4 certificate to the Commission when obtained. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 25 During today’s visit Ms Sowambur stated her line manager had been off on long term leave and that the Surrey and Borders NHS Trust had recently recruited internal verifiers and assessors and that she was still awaiting her coursework to be assessed. Ms Sowambur produced a letter from the Surrey and Borders NHS Trust thanking her for her application to attend the Registered Managers Award and NVQ Level 4 in Care training. Ms Sowambur explained that this was done for Surrey and Borders NHS Trust records and that her already completed coursework would be assessed. It is recommended that Ms Sowambur send a copy of her NVQ level 4 certificate to the Commission when obtained. A requirement was set at the key inspection that the registered manager ensures that weekly fire alarm checks are carried out and that all staff is aware of the location of the weekly record. The homes fire records indicate that regular weekly fire alarm checks are carried out. Ms Sowambur stated that all members of staff received advice on the location of the weekly recording book at the team meeting in January 2007. Ms Sowambur stated on the telephone on the 24th May 2007 that regulation 26 visits have been carried out at the home on a regular monthly basis. She stated that copies of the reports are available in the home for inspection. It was recommended at the key inspection that staff sign and date that they have read and understood all the homes new policies and procedures. Ms Sowambur produced evidence that all staff had read, dated and signed indicating that they understood all the homes new policies and procedures. Ms Sowambur produced the Landlords Gas Safety Certificate 31/08/06, Portable Appliance Testing Certificate March 2007 and a half yearly water treatment test was carried out by the Surrey and Borders NHS Trust maintenance department on the 27/02/07. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 (2) Requirement The registered manager must ensure that all staff is aware of the home’s policies and procedures for handling medicines so as to ensure that people are so far as reasonably practicable protected from harm. Timescale for action 22/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations It is recommended that where people need support with personal care tasks such as bathing, brushing teeth and shaving etc more detail and instruction should be recorded so that unfamiliar staff are aware of exactly how that person should be supported. So that the diverse needs of people who use the service are considered, care plans and person centred plans could include reference to how the service will meet their needs and preferences in relation to race, religion, gender, sexual orientation, age and disability. It is recommended that staff receives refresher training on diabetes and that the specialist diabetic nurse confirms in DS0000025755.V340019.R01.S.doc Version 5.2 Page 28 2 YA6 3 YA19 Birdhurst Gardens 4. 5. YA20 YA23 writing that staff are competent to administer insulin to people with diabetes. It is recommended that the registered manager carry out weekly medication checks to make sure that people are receiving their prescribed medication. It is recommended that all members of staff attend refresher training on adult protection. Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Birdhurst Gardens DS0000025755.V340019.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!