Inspection on 16/02/07 for Birkdale Park

This inspection was carried out on 16th February 2007.

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

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

Other inspections for this house

Birkdale Park 12/08/09

Birkdale Park 24/06/09

Birkdale Park 03/08/07

Birkdale Park 09/02/06

Birkdale Park 09/08/05

Birkdale Park 09/02/05

Birkdale Park 10/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Birkdale Park 6 Lulworth Road Southport Merseyside PR8 2AT Lead Inspector Miss Diane Sharrock Key Unannounced Inspection 16th February 2007 10:00 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 Birkdale Park DS0000017226.V316457.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. Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birkdale Park Address 6 Lulworth Road Southport Merseyside PR8 2AT Telephone number Fax number Email address Provider Web address Name of Registered Persons(s)/company (if applicable) Name of registered Manager (if applicable) Type of registration No. of places registered (if applicable) 01704 566055 Mrs Carol Patricia Cunningham Mrs Diane Furnivall Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include up to 25 OP Date of last inspection 9th February 2006 Brief Description of the Service: Birkdale Park provides nursing care for 25 older people. It is owned by Mrs C Cunningham and is managed by Mrs D Furnival. The home has been converted from a large house to a care home and is situated in a residential area of Southport. It is on the main bus route to town and is close to Birkdale village. Recreational areas comprise of a lounge to the front of the building and a conservatory overlooking the garden. This room is also used as a dining room. The home has single and double bedrooms but all rooms are currently used to provide single accommodation. There is lift access to both floors and the mezzanine level (floor not serviced by a lift) has 2 bedrooms. These bedrooms are accessed by a short flight of stairs and a chair lift has now been fitted. The home has 2 bathrooms with adapted baths to assist those who are less independent and a call system with an alarm facility. Gardens are landscaped to the front and rear; the rear garden is spacious and enclosed. The home has ample car parking space and a minibus is available for hospital appointments and trips out. Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a period of one day. Inspections involve measuring a number of standards considered as important by the Commission for Social Care Inspection. During the inspection discussions took place with 4 Staff and the inspector met with some Residents that were in the lounge area. A total of 10 comment cards have been submitted to CSCI. A selection of Comment cards were also left in the home to offer people further opportunity to give their opinion about the home. The Inspector completed this unannounced visit by looking at the homes records and undertaking a tour of the building. Feedback was given to the Manager and Nurse in Charge at the end of the inspection. The pre inspection questionnaire gave details for fees for the home ranging from £458.50 per week to £520 per week. What the service does well: The home environment is well presented, well maintained and the décor and furnishings and fittings in all communal areas are of a good standard. The majority of the comment cards received were very positive about the Staff and offered complimentary comments about the care. “…have been very pleased with the care and support provided by Birkdale Park.” Residents seen were dressed appropriately and looked well cared for. Staff were very enthusiastic and observed to have a good rapport with Residents and Relatives and noted to be very respectful and caring towards Residents. Most comment cards indicated that Staff were “always” available when needed, 5 indicated Staff were “usually” available and one comment stated, “sometimes short Staffed which makes it more difficult for the Staff who are on duty.” Most comment cards indicated that activities were available, however 3 Relatives felt their Relative was too poorly to be involved in any activity. 3 Comment cards indicated that activities were “sometimes” arranged. Some comment cards indicated they were happy with the food approximately 3 indicated they were “usually” happy with the food and 1 said “sometimes.” Each resident has a detailed care plan. The care plans include information on the Residents needs and medication records looked organised and well managed. Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Full feedback was given to the Deputy during and on conclusion of this inspection. Some areas were noted to need action taken and further evidence to be in place to meet most other standards. The Manager must review all care plans to ensure they are accurate and up to date and that they are able to demonstrate they can meet the diverse needs of Residents at the home. The home needs to also include the resident or their family were agreed, to be involved in setting up their care plans. (This was repeated at the last inspection.) An audit of the management of medications must take place to ensure all areas of medications are well managed to prevent stockpiling of various medicines. All Staff that work at the home must be provided with all types of mandatory training including Abuse awareness and are fully trained and experienced to support and protect Residents. (This was repeated at the last inspection) Training records must be updated to evidence training is managed appropriately and an action plan must be developed to say how the home will achieve a basic 50 of Staff with a care qualification in an national vocational qualification. Their needs to be an audit carried out with regard to Staff files to ensure all Staff employed at the home have appropriate support, training and recruitment. The current application forms must be developed to include details of previous employment, medical declaration and criminal declarations Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 7 were necessary. Supervision and appraisals must be developed to make sure all Staff are fully supported. The home must also include induction for all new Staff to ensure they are competent to care for the Residents. (This was repeated at the last inspection.) The company must demonstrate that the on-going Staffing levels are able to accommodate the changing needs and dependencies of Residents and must include all relevant persons opinions. The current situation of care Staff going from care to working in the kitchen must be stopped to stop any risk of cross infection. This will also make sure that Staffing levels are not affected in providing appropriate support to Residents in the mornings and evenings. A review of Staffing levels in the kitchen must take place to show what actions will be taken to provide appropriately trained Staff for preparing breakfasts and evening meals. Menus must be reviewed and advice sought from local dieticians, as it was noted sandwiches are served every evenings and there was a large supply of frozen vegetables and foodstuff in the freezers. Activities must be developed to meet the current Residents needs. Care plans should identify how they will meet the Residents social needs. Staff should have suitable training to assist them in supporting Residents socially, especially for those Residents identified as having Dementia and high dependency needs. The home does not have a person employed as an activities organiser. The current maintenance and decoration programme must include bedrooms due for refurbishment so they can achieve the same maintenance standards already achieved in communal areas. Residents should be included in these plans so they are aware and consulted in the décor of their bedroom. Cleaning schedules in the home should be reviewed to make sure an acceptable standard of hygiene is provided at all times. Some bedrooms doors were noted to be wedged open and not linked to any fire system. The Manager had individual risks in place, these should be reviewed to include the Registered Persons actions to minimise risks in the home with doors being wedged open with doorstops. The current dining tables are not suitable for current Residents to use at meal times. Suitable tables should be provided to help Residents enjoy meals with fellow Residents. Finance records of Residents monies managed by the Registered person must be updated and accessible to the inspector and Resident or their Representatives as necessary. Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 8 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. Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 9 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 Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed before moving to the home in order to ensure their needs can be met at the home. EVIDENCE: Most comment cards received stated they have received a contract and following the last inspection the Service User Guide had been updated. The Manager explained that this document is usually kept by the office but due to redecoration it was temporarily kept with the Manager. The Manager did not have a Statement of Purpose and discussion followed about the national minimum standards. The Manager was advised that a statement of Purpose must be provided and accessible to everyone to make sure Residents can make informed choices about the home. 3 Care plans were looked at during this inspection and one included a recently admitted resident. A Social Workers assessment and information gained from the hospital Staff and relative was also provided with the homes own Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 11 assessment to show they could meet the Residents needs before being admitted. Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home did not always show they were adequately managing Residents health and personal care needs. EVIDENCE: Three care plans were reviewed as part of case tracking Residents care. Individual plans of care are available and identify relevant aspects of health and personal care. One care plan was detailed and gave a good account of the Residents needs. In looking at another care plan however it was noted that the care plan had not been updated to include the care necessary to manage the Residents feeding tube, their catheter or pressure sore. Some reference was made in the monthly review but it was difficult to see if the care was helping the current pressure sore. Consideration must be given to the use of wound mapping or more accurate and detailed care plans which will help identify if the treatment given is helping the wound heal. Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 13 This highlighted the need for the Manager to review all care plans to ensure they are accurate and up to date and that they are able to demonstrate they can meet the diverse needs of Residents at the home. During interviews with Staff they were able to discuss the personal, nursing and social care needs and individual routines of Residents and explained how they gave that care. Various positive interactions were observed with Staff supporting Residents throughout the day. Most Residents seen during this inspection were noted to be quite poorly and sleepy and unable to chat to the inspector, one Resident declined to talk. Care plans and daily records did not give details about how the Residents social needs would be met. General discussion followed with Staff regarding this. Staff discussed the high dependency needs of some Residents and also some Residents who have dementia. They felt that if they had training in support for social care they might be able to meet their needs. The medication room was seen during this visit and most areas reviewed looked organised and showed a well-managed area. However it was noted with the Nurse on duty that there was a large storage of stock plies of certain drugs for some Residents, some offering several months supply from 2006. An audit of the management of medications must take place to ensure all areas of medications are well managed, regular audits will help evidence this area and will prevent large supplies of medications being stored. Birkdale Park DS0000017226.V316457.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home did not provide adequate support to all Residents to meet their social needs. Visitors are welcomed and included in the home at any time. Mealtimes and menus need review to offer suitable dining activities and sufficient balanced diets. EVIDENCE: Most comment cards indicated that activities were available, however 3 Relatives felt their Relative was too poorly to be involved in any activity. 3 Comment cards indicated that activities were “sometimes” arranged. The home currently does not employ an activities organiser but a recent Staff meeting advised that Residents opinions should be sought on what they would like to do. As stated previously many Residents are staying in their bedroom day and night and Staff try to provide support covering each floor. Most Residents do not socialise or meet up with other Residents and some are quite poorly with Staff describing their needs as being highly dependant and being unable to mix Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 15 with other people due to their dementia. This meant that Staff try to support to individuals in their own bedrooms. Activities must be developed to meet the current Residents needs. Care plans should identify how they will meet the Residents social needs. Staff should have suitable training to assist them in supporting Residents socially, especially for those Residents identified as having Dementia and high dependency needs. Staff felt that if they had training in activities for people with dementia and high dependency needs then they maybe able to meet the resident’s social needs. During this unannounced visit Relatives were observed visiting their families at any time. The Cook currently caters for different dietary needs e.g. diabetic diets and liquidised meals and has worked at the home for many years and was able to discuss the likes and dislikes of all the Residents. Some comment cards indicated they were happy with the food, approximately 3 indicated they were “usually” happy with the food and 1 said “sometimes.” Regular review of menus should also be sought from Residents and their Relatives to obtain their opinions and enable them to suggest changes to the current menus. The meal served during this visit was not listed in the menu for that day. Menus must be reviewed and advice sought from local dieticians as it was noted sandwiches are served every evenings and there was a large supply of frozen vegetables in the freezers, although Staff felt frozen vegetables and food e.g. pies, were mainly served at weekends. It was also noted that the majority of Residents lived in their bedrooms and had their meals in their own room. Just 4 Residents had their meal in the main lounge, however they were unable to sit at the dining table to enjoy the company of other Diners. Staff felt the tables could not accommodate the Residents Chairs. This must be reviewed to make sure the dining room furniture meets the needs of the Residents and that action is taken to support Residents in enjoying their meals with others. It was noted that the Cook works from 9am until 1pm and that currently care Staff are expected to go in the kitchen to prepare and serve breakfasts and the evening meal. The current situation of care Staff going from care to working in the kitchen must be stopped to stop any risk of cross infection. This will also make sure that Staffing levels are not affected in providing appropriate support to Residents in the mornings and evenings. A review of Staffing levels in the kitchen must take place to show what actions will be taken to provide appropriately trained Staff for preparing breakfasts and evening meals. Birkdale Park DS0000017226.V316457.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place for dealing with complaints and Residents know how to make a complaint. Systems are in place to protect Residents however these need to be clearly communicated to Staff. EVIDENCE: During Staff interviews some Staff had attended some of the mandatory training and were happy with the training on offer and that they had received Abuse awareness training. However some Staff had still not received this mandatory training but they were able to explain what they would do if they came across anything that concerned them and stated they would always report their concerns to the Manager and senior Staff. This must be addressed so that all Staff that work at the home are fully trained and experienced to support and protect Residents. (This point was repeated and is outstanding from the last inspection.) The Manager identified in November 06 that training needed to be reviewed and provided for Staff. However 4 months on and in looking at a sample of Staff records, some showed training records that had not been updated and identified that not all Staff had attended mandatory training such as Abuse awareness. Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 17 The home has a complaints procedure which is time scaled appropriately and includes contact details for the Commission. A copy of the complaints procedure is available to Residents. Birkdale Park DS0000017226.V316457.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is generally well managed and provides a pleasant environment for Residents to live in. EVIDENCE: A sample of areas throughout the home were seen during this key inspection. Accommodation is provided over 2 floors. Recreational areas comprise of a lounge to the front of the building and a conservatory overlooking the garden. This room is also used as a dining room. There is lift access to both floors and the mezzanine level (floor not serviced by a lift) has 2 bedrooms. These bedrooms are accessed by a short flight of stairs and a chair lift. The Pre inspection questionnaire gave details of refurbishment of the first floor shower room which had been decorated to a good standard. The conservatory and dining room had also been redecorated with new floorings to both lounge Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 19 areas. The conservatory would now benefit from blinds/covers to protect Residents once the summer weather commences. The home has a maintenance programme which looked well-planned and prioritised areas of repair and maintenance. The maintenance and decoration programme should include bedrooms due for refurbishment so they can achieve the same maintenance standards already achieved in communal areas. Residents should be included in these plans so they are aware and consulted in the décor of their bedroom. The majority of Residents were noted to be living in their bedrooms all day and night and the Manager felt rooms would be upgraded once a room was empty. However during this inspection it was noted that the home did have vacancies and appropriate planning should provide an effective decoration programme for bedrooms. A sample of bedrooms seen showed personalised rooms with various personal belongings. Some rooms seen on the first floor were noted to be in need of updating to match the standard of décor already achieved on the ground floor. The inspector looked at a sample of bedrooms in the morning and late afternoon and found that the bedrooms appeared to have not been hoovered. Cleaning schedules in the home should be reviewed to make sure an acceptable standard of hygiene is provided at all times. Some bedrooms doors were noted to be wedged open and not linked to any fire system. The Manager had individual risks in place. These assessments should be reviewed to include the Registered Persons actions to minimise risks in the home. These doors observed as being wedged open with doorstops also highlighted a privacy issues, especially were Residents were nursed in bed and were sleeping. Birkdale Park DS0000017226.V316457.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers are not consistently appropriate to ensure that the resident’s needs are being met effectively. Residents are supported by appropriately qualified Staff. Inductions are needed for all new Staff to ensure they are competent to care for the Residents. EVIDENCE: There is a long-standing Staff team who were observed to have a genuinely caring attitude towards Residents. Everyone in the lounge area was seen to be helped to feel comfortable. During interviews Staff were able to describe various courses and training they had recently attended and felt they were suitable to their needs. The Manager explained that they had purchased training packs, which she felt would improve the level of training opportunities in the home. Three Staff files were seen as part of case tracking records at the home. Most of the files were found to be organised and the pre inspection questionnaire gave details stating all Staff have had their police check, which ensures the safety of Residents. Those Staff that had oversees police checks have also had current police checks carried out by the Manager. Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 21 Two files for new Staff had no evidence of appropriate induction to support them in their role as a carer. The home must include induction for all new Staff to ensure they are competent to care for the Residents. (This was repeated at the last inspection.) All Staff that work at the home must be provided with all types of mandatory training including Abuse awareness and are fully trained and experienced to support and protect Residents. (This was repeated at the last inspection) Training records must be updated to evidence training is managed appropriately and an action plan must be developed to say how the home will achieve a basic 50 of Staff with a care qualification in an national vocational qualification. The homes pre inspection questionnaire gave no details of what percentage of Staff have achieved their care qualification. Their needs to be an audit carried out with regard to Staff files to ensure all Staff employed at the home have appropriate support, training and recruitment. 2 files were noted to have limited details for the application form with no spaces to list their previous employment, background so that gaps can be explored. The current application forms must be developed to include details of previous employment, medical declaration and criminal declarations were necessary The company must demonstrate that the on-going Staffing levels are able to accommodate the changing needs and dependencies of Residents and must include all relevant persons opinions. Most comment cards indicated that Staff were “always” available when needed, 5 indicated Staff were “usually” available and one comment stated, “sometimes short Staffed which makes it more difficult for the Staff who are on duty.” During Staff discussions it was noted that Staff felt it was difficult to prepare meals and provide care and support to Residents and felt it impinged on their caring role. Birkdale Park DS0000017226.V316457.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally organised. The health, welfare and safety of Residents and Staff is promoted and protected. EVIDENCE: The Registered Manager has been in post for approximately 10 years now. She has many years experience in a senior capacity in the care sector. The company have various procedures in place to show how the home is being managed e.g. the inspector looked at a sample of maintenance certificates, fire safety checks, risk assessments, accident records which showed what actions were taken to ensure the safety of everyone at the home. Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 23 The Manager and general Manager had organised monthly Staff meetings right through 2007. This should ensure that Staff members have a regular forum to discuss issues that may affect the service provided to Residents and the implementation of polices, procedures and practices within the home. Staff files had not been updated with training records or supervisions and appraisals for some Staff. However Staff did say they felt the benefit of such supervisions when carried out. Supervision and appraisals must be developed to make sure all Staff are fully supported. The Owner discussed her procedures for managing the finances for 1 Resident who she is appointee for. All records are kept with the Accountants. The cook manages the general shopping for most Residents and uses a booklet to provide details for Relatives/ Residents to be invoiced. The Resident whose appointee is managed by the home had some recorded expenditure but there was no updated balance of credit stored by the home. These records and all processes and paperwork used for managing Residents monies must be available for the inspector and the Resident or Relative were able. Procedures must be developed to describe what actions are taken to manage Residents monies so the home can evidence good practice in meeting this standard. The Manager produced a Quality Assurance file during this visit which had evidence of previous audits carried out at the home in recent years. This documents would benefit the management of the home if updated and regularly used to evidence quality assurance checks, especially for care plans, medications, activities, environment and health and safety, training and Resident questionnaires and opinions. Birkdale Park DS0000017226.V316457.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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 25 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 Persons(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18 1)a)c) Requirement The Registered Persons are required to ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of Service Users. The Registered Persons must ensure that all Staff have necessary training to meet the needs of Residents at the home including e.g. abuse awareness, The Registered Persons are required to, after consultation with the Service `Users, or a representative of his, prepare a written plan (the Service User’s plan) as to how the Service Users needs in respect of his health and welfare are to be met and to keep the Service Users plan under review. The Registered Persons are required to ensure that any unnecessary risks to the health and safety of Service Users are identified and so far as possible eliminated. The use of Door DS0000017226.V316457.R01.S.doc Timescale for action 18/05/07 2. OP7 15 1(2b) 18/05/07 3. OP38 13 4c) 18/05/07 Birkdale Park Version 5.2 Page 26 wedges must be reviewed and appropriate actions taken to safeguard Residents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Persons/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The Registered Persons must ensure the Statement of Purpose is submitted to CSCI and openly accessible at the home. The Registered Persons must ensure all Residents or their relative, where agreed, are fully involved with setting up the care plan. The Registered Persons is required to provide updated care plans to all Residents that give accurate details necessary for their care and support. The Registered Persons must ensure that all new Staff has an induction within six weeks of employment. This must be evidenced through documentation. Application forms should be updated to included employment history, medical and criminal declarations. The Registered Persons must ensure that Staff at the home receives appropriate supervision with records kept. The Registered Persons must include bedrooms in the homes refurbishment programme. To provide suitable dining tables for use of Residents currently at the home. To provide protective coverings to the conservatory roof and windows. The Registered Persons should develop quality assurance systems in most areas such as medications, care plans, DS0000017226.V316457.R01.S.doc Version 5.2 Page 27 2. OP7 3 OP30 4 5 OP36 OP19 6 OP33 Birkdale Park 7 8 6 OP35 OP15 OP12 activities, health and safety etc to assist in the overall management of the home. The Registered Persons must provide access to all records and procedures relating to the management of Residents monies and finances. The Registered Persons must review the current menus including evening and weekend meals. The Registered Persons must develop suitable activities and support for Residents at the home. Suitable training in activities should also be provided to assist Staff in social support. Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Birkdale Park DS0000017226.V316457.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!