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Inspection on 29/09/05 for Birdsgrove Nursing Home

Also see our care home review for Birdsgrove Nursing Home for more information

This inspection was carried out on 29th September 2005.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The management and staff use the document tools for care planning and delivery well, which ensure the whole wellbeing of the service users are provided for. A good basic training and staff development programme is in place that includes the domestic, catering, laundry and maintenance staff. This has reflected in the improvement in the standard of care services provided.

What has improved since the last inspection?

There has been an overall great improvement in the quality of record keeping. The activities provided for residents has been developed and training for staff for protection and health and safety of service users has been provided. The complaints and concerns received by the home have been handled well. A programme to improve parts of the decoration, furniture and fixtures of the home has been started to make sure the comfort and wellbeing of the service users is better. Service users and their relatives in general gave positive comments to care given and staff working in the home.

What the care home could do better:

That they monitor regularly that all staff adhere to the policies and procedures for medication administration and infection control.

CARE HOMES FOR OLDER PEOPLE Birdsgrove Nursing Home Warfield Road Bracknell Berkshire RG12 2JA Lead Inspector Ruth Lough Unannounced Inspection 29th September 2005 08:05 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 Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 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. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Birdsgrove Nursing Home Address Warfield Road Bracknell Berkshire RG12 2JA 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) 01344 422261 Southern Counties Care Limited Mary Jane Katherine Slater Care Home 87 Category(ies) of Dementia (20), Old age, not falling within any registration, with number other category (67) of places Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users not to be admitted under 60 years of age for long term care. Service users under 60 years of age to be admitted for respite care only. 13th December 2004 Date of last inspection Brief Description of the Service: Birdsgrove Nursing Home is registered for 67 Old Age (OP) and 20 Dementia(DE) service users above the age of 60 years and is part of a group of care homes belonging to Craegmoor Healthcare ( Southern Counties Care Ltd). The home is situated on the borders of Bracknell town within a residential area on the main thoroughfare to the village of Warfield. The home is divided into three units determined by the development of the establishment over time. The Surrey Unit ( 25 ) originally a large converted domestic home, the Berkshire Unit ( 42 ) a purpose built 2 storey extension, and the Kent ( 20 ), built within the last decade for service users with dementia. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit to review the quality of service provided and the outcomes for the service users living in the home. The inspection visit took approximately 6 hours with two inspectors and involved looking at records, tour of the home and discussions with service users relatives, visitors and staff. What the service does well: What has improved since the last inspection? What they could do better: That they monitor regularly that all staff adhere to the policies and procedures for medication administration and infection control. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 6 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. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 The assessment of need carried out prior to admission to the home ensures that the service users needs, can be met by the services, facilities and staff skills. EVIDENCE: The inspectors reviewed samples of service users care files from all 3 units in the home and was able to determine from those that a thorough assessment process is carried out prior to admission. The home takes the opportunity to obtain information from the referring health and social care professionals and incorporates this with information from the service users relatives where possible. The inspectors were informed that the home is undertaking a trial of new document tools for this purpose for the company and are hoping that these will be more effective tools to use. The service users care files, training programme and observations of the care carried out supported that service users care and social needs are being met by the home. The service users, where able, and their relatives expressed that they were happy with the care provided. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 The service user plans are holistic in content and ensure that their health needs are met. The policies, procedures and processes for safe medication administration are in place, the poor practice in one unit if the home is not reflected generally. EVIDENCE: The quality of the service user care plans has greatly improved since the last inspection visit as staff are using the documentary tools effectively to ensure that care is carried out according to the individuals needs. The plans include the appropriate monitoring of the service users, skin integrity, nutritional, fluid balance and mental health. The home uses body maps and photographs where a perceived risk or health needs indicate. Health and safety risk assessments, plans for moving and handling and the environment are carried out with reference to the individual. The care plans reflect the involvement of the service users and their relatives and incorporate their choices of how they wish to live. The staff are recording well the outcomes and all parts of the plan are reviewed and amended accordingly on the regular basis. Care staff and the Registered Nurses both contribute to the information recorded. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 10 Evidence to support that service users are enable to continue with obtaining other resources of healthcare treatment external to home was recorded in the care plans. Dental, hearing and eyesight treatment is accessed regularly. A visiting Chiropodist attends to those who need treatment and the home employs a physiotherapist to support service users to remain as mobile and able as possible. The policies, procedures and processes for the storage and administration of medication’s are in accordance to regulations and the Nursing and Midwifery Council Code of Professional Conduct. An omission in recording the administration of the morning medications in one unit was highlighted during the inspection process and has been reflected in the scoring of this standard. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The home encourages and supports service users to continue with their daily lives and social lives in accordance to their choices and physical and mental health needs. EVIDENCE: The care plans and discussion with service users, staff and relatives supports that the home has a good programme of activities that is made available to all service users. The care plans have detailed information of the choices made by the service users of how they wish to live and staff have recorded well the outcomes for the individual, in the majority of those care files reviewed. Two members of staff are employed to provide for an average of 60 hours a week, Monday to Friday social, group and one – to – one activities. The nursing and care staff provide support during the week and at the weekends. Schedules of events are advertised in the home and have included quizzes, bingo, videos, exercise sessions, dancing, singing and arts and crafts. Other visiting entertainers come into the home inclusive of music performances by choirs, soloists and small groups and the home makes welcome the Pat a Dog scheme. Celebratory events such as Christmas, Halloween and birthday parties are planned for the future. Visitors and relatives are able to visit the home in accordance to the service users wishes although the home is limited to areas of privacy other then the service users rooms. The service users are actively encouraged to decorate Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 12 and furnish their rooms with their personal possessions within the limitations of safe working practices, room sizes, and the fixtures and fittings. Records of the service users personal property brought into the home are recorded in the individuals care plans. Service users and families were complimentary about the menu and food provided. The nutritional status and food preferences are recorded in the care plans and staff pass to the catering department these and individuals choices for the day. Alternatives to the main meal are made available and if wished, extra snacks are provided where the service user requests, to support medication needs or ill health dictates a supplementary diet. Service users are able to eat their meals in their rooms and some dining/ sitting room facilities are available although extremely limited due to the design of the building. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Complaints and concerns are handled in accordance to the complaints policy and procedure and appropriate actions taken. The service users are protected from possible abuse by the homes policies and the training provided to staff. EVIDENCE: The complaints policy and procedure is compliant to the regulations and the National Minimum Standards. The home has suitable systems to document concerns or complaints and has developed monitoring tools for the management to observe trends and that appropriate action has been taken. The home recorded 13 incidents of concerns since the last inspection of which 5 have been complaints, the others have been notification of serious incidents and hospital admissions. The information recorded and gained from speaking to service users and their representatives supported that the home has improved in its management of concerns and complaints made since the last inspection. Service users are supported to take part in their civil rights through relatives and friends as advocates and the ability to vote should they wish to. The home has suitable information, policies and procedures for the prevention of abuse in the home. The staff are trained through the induction process and foundation training and a rolling programme of training that is carried out in the home. Senior members of the management team have attended suitable training appropriate to their roles and in order to deliver training to the rest of Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 14 the staff. The policies and procedures for ‘whistle blowing’ are prominently displayed in all staff areas. Some staff have attended training for dealing with service users with challenging behaviour in order to support their roles. Staff are given guidelines during their induction in regard to protecting service users finances and property. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The home has improved is standard of hygiene and has developed its systems to prevent cross infection. EVIDENCE: The home generally had a higher standard of cleanliness all over the premises and it was evident that a renewal programme of soiled carpets and floor coverings was in process. The laundry facilities are kept tidy and suitable equipment is place to maintain the service well. The development of an area for the sorting and folding process of clothing would enhance the appearance of the clothes when they are returned to the service users. The home has increased its staffing levels for the laundry service that includes staffing over the weekend periods that has reflected in the quality and speed of the service and has reduce the time of carers being away from the direct delivery of care. Hand washing facilities with the appropriate liquid soap and paper towels are available in areas of where soiled linen and disposable goods are handled. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 16 One care assistant was observed to be handling soiled disposable pads inappropriately and not in accordance with the homes policies and procedures. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard not assessed during this inspection. EVIDENCE: As above. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 The home has suitable COSHH, Safe Working Practices processes in place to protect the service users, staff and visitors. EVIDENCE: This standard was partially inspected with inspectors reviewing the homes information, training and management for COSHH and health and safety. The home has ensured that the required information for the Control of Substances Hazardous to Health and health and safety topics are available to staff. The staff have training for safe working topics in the induction and foundation programme and a rolling programme of training is carried out for the rest of the staff team inclusive of maintenance, domestic, laundry and catering staff. Senior staff have attained the required training in order to provide regular training sessions in the home. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 19 The kitchen/catering staff have recently received an award for their food hygiene standards. Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 20 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 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 3 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Birdsgrove Nursing Home DS0000010975.V249737.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 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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