Inspection on 23/09/08 for Birdscroft Nursing Home

This inspection was carried out on 23rd September 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birdscroft Nursing Home 11/09/07

Extracts from inspection reports are licensed from CQC, this page was updated on 05/12/2008.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Birdscroft Nursing Home 16 Highfields Ashtead Surrey KT21 2NL     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Mary Williamson     Date: 2 3 0 9 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 25 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 25 Information about the care home Name of care home: Address: Birdscroft Nursing Home 16 Highfields Ashtead Surrey KT21 2NL 01372274499 01372276006 murielsandy@asterhealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) St Dominic`s Ltd Type of registration: Number of places registered: care home 28 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 28. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP). Date of last inspection Brief description of the care home Birdscroft Nursing Home is a registered home, providing nursing care for up to twentyeight elderly residents. The home is situated in a residential avenue located within the village of Ashtead. Accommodation is provided in both single and double rooms, some of which have en-suite facilities. The rooms are arranged over two floors and there is a shaft lift in place to access the first floor. There is a small garden to the rear of the property, which is accessible by a ramp. A limited amount of parking space is available 0 Over 65 28 Care Homes for Older People Page 4 of 25 Brief description of the care home at the front of the home. The fees charged in this home range from £550 to £735 per week. Information provided on 23/09/2008. Care Homes for Older People Page 5 of 25 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was the first site visit of a key inspection and was unannounced. The inspection was undertaken by Mary Williamson Regulation Inspector over a period of five and a half hours. The home manager represented the organisatin for the duration of the inspection. People who use the service wish to be referred to as residents and therefore the term resident is used throughout the report. A tour of the premises was undertaken and records relating to the care of the residents and the management of the home were examined. Care Homes for Older People Page 6 of 25 It was possible to meet all the residents in the home and talk to some in more detail than others, about their views on the home. It was also possible to meet five relatives who visited the home during the inspection. Leisure activities were observed, together with staff and residents interaction. Information was also obtained from the Annual Quality Assurance Assessmnet which was provided by the manager prior to the inspection. Discussions were held with staff either individually or in groups to gain feedback regarding their experiences of working in the home. The CSCI would like to thank the residents, relatives, staff and management for their help and hospitality during the inspection. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get Care Homes for Older People Page 8 of 25 printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 25 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 25 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is sufficient information available to prospective residents to help them choose if they want to live in the home. There are shortfalls in contracts of occupancy which means that not all residents have access to a copy of terms and conditions of the home. Standard six is not applicable. Evidence: The home has a statement of purpose and service user guide in place. This is available to all prospective residents and their relatives providing them with suficient information to make a choice abot living in the home. Contracts of occupancy were in place for some residnets others, were in the process of being drafted electronically. The manager stated that all residents would have a contract of occupancy by 30th September and that this would be confirmed by him in Care Homes for Older People Page 11 of 25 Evidence: writing to CSCI. The home does not provide intermediate care. Care Homes for Older People Page 12 of 25 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents health and presonal care needs are outlined in well maintained care plans. Appropriate arrangements are in place to meet the health care needs of residents. The medication policy in place protects residents living in the home. Residents are treated with dignity, privacy, and respect. Evidence: Individual care plans sampled are detailed and outline the specific personal and social care needs to be undertaken. Care plans are well maintained, and well written based on pre admission needs assessments, input from residents and their relatives, and other health care professionals. They are reviewed and updated to reflect the changing needs of residents. Risk assessmnets are included in care plans. The home has arrangements in place to meet the health care needs of the residents. All residents are registered with local GPs who visit the home on request. There is also access to chiropody, an optician, dental care and physiotherapy as required. The manager stated that there is access to a tissue viability advisor, and various pressure Care Homes for Older People Page 13 of 25 Evidence: relieving equipment is provided in the home. The medication policy in place protects the residents living in the home. Medication is administered according to this policy and the Nursing and Midwifery Council (NMC) Code of Professional Conduct. There are good audit trails of medication entering and leaving the home. The medication recording charts are well maintained and residents medication is reviewed regularlu by the GP. Privact and dignity is observed and staff were seen to be polite and respectful when interacting with residents. Personal care is undertaken in private, and staff knock on bedroom doors prior to entering. Care Homes for Older People Page 14 of 25 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The activity arrangements in place meet the residents individual and collective needs. Famliy links are maintained and relatives are encouraged to take an active part in the home. The nutritional needs of the residents are met. Evidence: The home operates an activity programme which includes music and movement, keep fit, coffee mornings, outside entertainers, board and card games, and sing alongs. Residents were playing bingo in the lounge during the inspection. Staff said that they take residents for local walks and that residents like to sit in the garden depending on the weather. A relative commented that more organised outings would be appreciated. The home had organised a party the previous week and residents and relatives stated that they really enjoyed it. Links are maintained with family and friends and visitors are welcome in the home at any time. The four relatives spoken to said thet they are made to feel welcome whenever they visit Relatives are included in the care planning process and are invited to attend reviews of care. Spiritual needs are supported and various local clergy will visit the home on request. The manager stated that residents like to watch songs of praise on television on Sunday evenings. Care Homes for Older People Page 15 of 25 Evidence: The catering arrangements in the home are good. Menus are planned over four weeks taking into account residentss needs, likes, dislikes and choice. Lunch was observed and the food offered was appetising, wholesome, and nutritious. Drinks and snacks are served throughout the day. Staff were seen offering sensitive support to residents who required help with feeding. The home has access to the advice of a dietician. Residents stated that the food was very good and that they had a choice. The kitchen is well organised, clean and hygenic. The cook has a current food hygiene certificate. Care Homes for Older People Page 16 of 25 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedure and the safeguarding procedure in place protect the residents living in the home. Evidence: The home has a complaints procedure in place. This is available to all residents and relatives in the service user guide. There is also a copy of this displayed at reception. There has been one complaint received by the home since the last inspection which was sucessfully resolved using the homes procedure. The home also has a safeguarding procedure in place. All staff unsretake safeguarding of vulnerable adults training and are confident that if a situation occured their concerns would be listened t and acted upon. There is also a copy of Surreys Multi Agency Policies and Procedures on Safeguarding Vulnerable Adults in place. The home was recently investigated for allegations of misconduct under these procedures with a satisfactory outcome. The home manager is new to post and dispite having safeguarding training with another local authority it is recommended that he attends the Surrey safeguarding training as soon as posible. Care Homes for Older People Page 17 of 25 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The current layout of the home is not suitable for its stated porpose. Shortfalls in the environmental standards means that reidents do not live in a well decorated home. The home is clean and hygenic. Evidence: A tour of the premises was undertaken. It was possible to view residents rooms and to get feedback about the facilities offered. A relative stated that she could not fault the care but the premises were unsatisfactory. The manager stated that planning permession had now been obtained to commence building work to extend bedrooms on the ground and first floors to include en-suite facilities. This also included extending the lounge area. Currently the bedrooms vary in standard with some having been recently redecorated, and the majority in need of refurbishing. A requirement has been made that the provider informes the CSCI in wtiting of the proposed date the building work will commence and the duration of his work. The standard of cleanliness in the home is good. There is an infection control policy in place and all staff undertake training in this policy. Care Homes for Older People Page 18 of 25 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The number and skill mix of staff employed in the home is sufficient to meet the assessed needs of the residents currenlly living there. The staff recruitment procedure in place protects the residnets. Evidence: The staff duty rota was seen and confirmed that the number and skill mix of staff on duty was sufficient to meet the assessed needs of the residents. The manager covered staff sicknedd on the day of the inspection. Individual staff training and develpoment files were seen. All staff undertake an induction programme based on Socila Care Councils skills for care. Mandatory training is coordinated by the manager and records maintained of when individua training is due. This includes manual handling, first aid, food hygiene, safeguarding vulnerable adults, fire safety, risk assessmnet. There is a staff recruitment procedure in place that protects residents living in the home. Thre staff employment files were sampled and include written references, an employment history, and a CRB (Criminal Records Bureau) dicclosure. Care Homes for Older People Page 19 of 25 Care Homes for Older People Page 20 of 25 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed in the best interests of the residents. Systems are in place to monitor quality assurance. The health, asfety, and welfare of residents and staff are promoted. Evidence: The home is managed by a manager recently appointed to post in July 2008. He is a qualified nurse with several years experience, and holds a certificate in management studies. The manager has not yet submitted an application to become the registered manager of the home. The inspector was informed that a deputy manager has been recruited to commence employment on 1/10/2008. The home also has management support of the provider and operationals director. Quality assurance is observes and systems in place for monitoring include regulation 26 visits, residnets meetings, residents and relatives feedback questionnaires, medication audits, care plan audits, catering audits, and maintenance audiys. The Care Homes for Older People Page 21 of 25 Evidence: comments recorded from the questinnaires include the care is excellent, I cant fault the care, the nurses are very kind, the food is excellent, and I lke living here. The home has a policy for safeguarding residents financilal affaire. No financial transactions are handled by the home on behalf of residents. Relatives or designated representatives manage finance if residents are unable to do so. Health and safety is observed, and there is a health and safety policy inplace. All staff undertake health and safety training and examples of good practice were noted including appropriate use of hoists, gloves, and aprons. Risk assessmnets are in place. All identified risks have been assessed to promote health and safety and safe working practice. Fire safety is observed and all staff undertake fire safety training. The home has a contract in place for the maintenance of fire fighting equipment and emergency lighting. Accidnets are recorded appropriately. Care Homes for Older People Page 22 of 25 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 19 23(2)(a) The physical design and 14/10/2007 layout of the home to be used as the care home must meet the needs of the residents. This must include appropriate communal areas including a dining room to reflect the number of residents living in the home and a lounge where residents can sit and watch television. Care Homes for Older People Page 23 of 25 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 19 23 The registered provider is required to ensure that all parts of the care home are decorated to a good standard. To enable residnets to live in a home that is well decorated, comfortable and homely. 28/10/2008 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 18 It is recommended that the manager attends training in Surreys Multi Agency Safeguarding Vulnerable Adults policies and procedures as soon as posible. It is recommended that the registered person submittes an application to the CSCI for the home manager to be registered. This is viewed as good practice in the abscence of a registered manager for the nine months. 2 31 Care Homes for Older People Page 24 of 25 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 25 of 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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