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Inspection on 01/09/05 for Birtley House Nursing Home

Also see our care home review for Birtley House Nursing Home for more information

This inspection was carried out on 1st 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

Service users spoken with expressed their satisfaction with their quality of life and the care they receive at the home. One service user stated he was very happy and another commented that `This is a very good nursing home. I only have to ring a bell and the nurse comes.` A visitor commented how she was always made to feel welcome and appreciated being able to join her relative for a meal at the home. The staff training and procedures in place at the home ensure that the service users` rights to privacy and dignity are respected. Individual choice and autonomy was seen to be encouraged.

What has improved since the last inspection?

The ongoing maintenance, redecoration and refurbishment programme provides service users with a safe and comfortable environment in which to live.

What the care home could do better:

Requirements have been that the home tighten their recruitment procedures and plan action based on the results of service user surveys.

CARE HOMES FOR OLDER PEOPLE Birtley House Nursing Home Birtley Road Bramley Guildford Surrey GU5 0LB Lead Inspector Denise Debieux Unannounced 1 September 2005 @ 10:00am st 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 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. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Birtley House Nursing Home Address Birtley Road Bramley Guildford Surrey GU5 0LB 01483 892055 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Eyhurst Court Limited To be confirmed CRH - Care Home 47 Category(ies) of OP - Old Age (47) registration, with number PD - Physical Disability (3) of places Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 - Including 3 beds for Physical Disability (PD) for persons of not less than 50 years. 2 - 3 double bedrooms to be used for shared occupancy. Date of last inspection 21 April 2005 Brief Description of the Service: Birtley House has been providing care for over seventy years and is registered to provide nursing care for forty-seven service users. The home has remained with the same family over this time and is now run by the grandchildren of the first owner. The home is set in its own grounds and is surrounded by a range of gardens, e.g. rose garden, kitchen garden, walled garden and orchard. Adjacent to the house and in walking distance is a large pond, which is a nature reserve. The home has forty-one single bedrooms and three double bedrooms. The rooms are well decorated and a range of facilities are provided, e.g. telephone point, television. The registered manager has recently retired and the home have now appointed her successor who will shortly be applying to the CSCI for registration as the registered manager. The matron (manager) of the home oversees all the clinical practice of the home and day-to-day work. The owners/directors support her in this role and take direct responsibility for the administration and practical running of the home. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service. Mrs Jackie Sadler (Matron) and Mr John Valentine (Compliance and Training Officer) were present as representatives for the establishment. A partial tour of the premises took place. Two care plans, six staff files, staff training records and medication documentation were all sampled. Two of the service users were spoken to at length, in private, with a further three service users and one visitor being spoken with during the tour. The inspector would like to thank the staff and service users for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? The ongoing maintenance, redecoration and refurbishment programme provides service users with a safe and comfortable environment in which to live. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 6 What they could do better: 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. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 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 standard(s) 5 Prospective service users (and/or their representatives) are invited to visit the home and move in for a trial period before they make a decision to stay. EVIDENCE: Following the initial enquiry the matron will contact the service user or their representative and establish that the service user falls within the home’s category of registration. A further assessment will then take place with the matron usually visiting the service user in their own home or hospital and obtaining further information from GP’s and other health and social care professionals as needed. The service user and/or their representative are invited to visit the home for a tour and to meet the staff. Admission to the home is on a six week trial basis. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 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 standard(s) 9 and 10 Policies, procedures and practices are in place to ensure the safe handling and administration of medication. The arrangements for health and personal care ensure that service users’ privacy and dignity are respected. EVIDENCE: The medication administration record sheets, medication storage, controlled drug storage and controlled drug record book were all sampled during this inspection and found to be accurate and well-maintained in line with the home’s policies and procedures and current legislation. During the tour of the home staff were observed to always knock before entering the service users’ bedrooms and all interactions observed between staff and service users were seen to be caring and respectful. Service users spoken with confirmed that they felt the staff respected their privacy. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 10 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 standard(s) 14 Service users are encouraged and enabled to exercise choice and control over their lives. EVIDENCE: The routines of daily living are arranged to suit individual service users’ preferences and choices. This was reflected in the care plans sampled and confirmed by service users spoken with. Service users are able to choose which activities they attend or participate in and one service user stated that ‘The food is excellent, there are always plenty of choices’. Service users handle their own financial affairs where appropriate. The inspector was advised that the home do not handle the financial affairs of any service users. The service users’ rooms seen all contained many personal possessions and were arranged to suit the service users’ wishes. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 11 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 standard(s) 18 All required policies and procedures are in place to ensure that service users are safeguarded from harm or abuse. EVIDENCE: The home has a copy of the latest Surrey Multi-agency Procedure for the Protection of Vulnerable Adults and training to all staff is included in the home’s staff training programme. It has been recommended that the new matron arrange to attend a course to familiarise herself with the Surrey local procedure. All of the service users spoken with said they felt safe at the home, with one commenting ‘Absolutely’. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 12 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 standard(s) 20 The communal facilities at the home are comfortable, safe and well maintained. EVIDENCE: The home is set in its own extensive grounds and is surrounded by a range of gardens, e.g. rose garden, kitchen garden, walled garden and orchard. Adjacent to the house and in walking distance is a large pond, which is a nature reserve. A good range of communal facilities are available, which include a number of sitting rooms, dining rooms, an activities room and an indoor sun area. All communal areas are accessible to the service users and provide them with pleasant and homely surroundings in which to live. Service users spoken with all commented on how much they enjoyed the views and grounds at the home. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 29 and 30 The home has a comprehensive staff training programme which is designed to ensure, as far as reasonably possible, that service users are in safe hands at all times. Action must be taken to improve the staff recruitment procedures to ensure that service users’ safety is protected. EVIDENCE: The home is working towards having 50 of their care workers qualified to National Vocational Qualification (NVQ) level 2 in care or higher by 31st December 2005. Two of the twelve care workers have already achieved the qualification and four are currently on the course. The home has a comprehensive training programme which covers all areas required by the Skills for Care organisation (previously TOPSS). Staff training records were inspected and found to be well maintained with all staff training up to date. Six staff files were reviewed and were found to contain the majority of the information required. However, the files seen did not include verifications of reasons for leaving previous jobs and gaps in employment were not fully explained. The home obtains two written references and applies for Criminal Record Bureau (CRB) checks for all staff. In some instances staff commence employment on the basis of a POVAfirst check whilst waiting for the CRB certificate to be returned. In these instances measures had not been put in place in line with recent legislation. Requirements have been made regarding these areas of recruitment. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 14 All interactions observed between the staff and service users during this inspection were seen to be caring and respectful. One service user commented that ‘there are plenty of staff around, they are very good.’ Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 35 There is a quality assurance and monitoring system in place that is based on seeking the views of the service users, but the home needs to draw up an action plan and act on the results of the last survey. Policies and procedures are in place to protect service users’ financial interests. EVIDENCE: In the previous report it was stated that: ‘The home has recently completed a full survey of all service users, their representatives and visiting health care professionals. The inspector was advised that the results are currently being correlated. Once completed the home will draw up an action plan for issues identified as needing improvement and will produce a report of the findings.’ The home still needs to complete this process, draw up an action plan and produce a report. This was discussed at this inspection and a requirement has been made. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 16 In 2003 the home achieved an ‘Investors in People’ award. The inspector was advised that the home have recently had a ‘post recognition review’ of their practices, by the organisation concerned, which has re-confirmed that they still meet the required standard for the award. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION x 3 x x x x x x STAFFING Standard No Score 27 x 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x 2 x 3 x x x Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 18 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 29.2 Regulation Requirement Timescale for action 01.09.05 2. 29.3 19(1)(a-c) The registered person shall not employ a person to work at the care home unless the person is fit to work at the care home and he/she has obtained, in respect of that person, the information and documents specified in paragraphs 1 to 9 of Schedule 2 of the Care Homes Regulations 2001, as amended by The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. 19(11) Where the registered person (a-c) permits a new worker to start work with a POVAfirst check but prior to receipt of a valid CRB certificate the registered person must: - Appoint a member of staff (the staff member), who is appropriately qualified and experienced, to supervise the new worker. - So far as possible, ensure that the staff member is on duty at the same time as the new worker. - Ensure that the new worker does not escort service users H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc 01.09.05 Birtley House Nursing Home Version 1.40 Page 19 3. 33.2 33.4 24(1)(2) away from the care home premises unless accompanied by the staff member. The registered person must draw up an action plan to address issues identified in their last service user survey, produce a report, send a copy to the CSCI, Eashing office and make the report available to service users. 01.11.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 18 Good Practice Recommendations It is recommended that the new matron arrange to attend a Surrey Multi-agency Procedure for the Protection of Vulnerable Adults training course. Birtley House Nursing Home H58 H09 S17594 Birtley House V240527 010905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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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