Inspection on 12/12/06 for Birtley House Nursing Home

This inspection was carried out on 12th December 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Birtley House Nursing Home 04/09/07

Birtley House Nursing Home 01/09/05

Birtley House Nursing Home 08/09/04

Birtley House Nursing Home 13/04/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Birtley House Nursing Home Birtley Road Bramley Guildford Surrey GU5 0LB Lead Inspector Joseph Croft Unannounced Inspection 12th December 2006 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 Birtley House Nursing Home DS0000017594.V318655.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. Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 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 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) Eyhurst Court Limited Jacqueline Joy Sadler Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47), Physical disability (3) of places Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Including 3 beds for physical disability (PD) for persons of not less than 50 years 3 double bedrooms to be used for shared occupancy. Date of last inspection 1st September 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 within 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 manager (matron) 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 aspects of running of the home. The weekly fees range from £735 to £1085. Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit forms part of the home’s first key inspection to be carried out in the Commission for Social Care Inspection (CSCI) year, April 2006 to June 2007. The inspection was carried out under the CSCI “Inspecting for Better Lives” programme. The inspection was undertaken by Mr J Croft and Mrs S Holland on the 12th December 2006 and took eight hours to complete, commencing at 10:00 hours and concluding at 18:10 hours On arrival at the home the inspectors were made aware of the absence of the registered manager, Mrs Jacqueline Sadler, but she joined the inspection at approximately 10:30 hours. The registered responsible individual, Mr Simon Whalley and Ms Margaret van der Walt, Deputy Manager were present and assisted until the arrival of the manager. A tour of the home was undertaken, where the inspectors took time to speak with various members of staff, residents, their relatives and visitors to the home. Lunchtime was observed, during which residents commented positively on the food and different choices that are always available. The second part of the inspection was spent reviewing residents care files, sampling policies and records and sampling care workers’ recruitment files. A pre-inspection questionnaire had been supplied to the home and this had been completed and returned within the requested timescale. Some of the information from the questionnaire will be referred to in this report. A number of CSCI feedback forms were supplied to the home for distribution to residents, relatives and visitors and healthcare professionals involved in the support of residents. The inspectors would like to thank all those who completed and returned the questionnaires. The inspectors would like to thank the residents, staff and management for their hospitality, time and assistance. Eleven requirements and three recommendations have been made during this inspection. What the service does well: Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 6 The needs of residents are assessed prior to their admission to the home. A wide range of seasonal entertainment and activities are made available to residents and residents are supported to be part of the local community. Residents’ preferences are respected and accommodated. A varied, wellbalanced selection of meals is offered and the meals served appeared appetising. The home provides adequate communal and individual living space making it a safe and comfortable place to live. Improvements to the facilities of the home continue to be made to enhance the bedrooms and living areas for residents. Over 50 of the care staff working at the home holds the minimum of an NVQ level 2 or above. What has improved since the last inspection? What they could do better: The registered person must make resident’s plans of care available to residents, must keep the care plans under review and must revise the care plans when appropriate, to reflect changing needs and how these are to be met. Unnecessary risks to the health or safety of residents must be identified and so far as possible eliminated. The registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person must make a referral to the Protection Of Vulnerable Adults (POVA) list for the identified employee who was dismissed from their duties in line with POVA procedures. All staff must receive training in the Protection of Vulnerable Adults. All recruitment files must have reasons for gaps in employment recorded, and two written references. Staff must receive a minimum of six formal one to one supervision sessions per year. A record of all training undertaken by staff, including induction training must be included in individual staff files. All staff must receive training on Infection Control. The registered person must ensure fire doors are not propped open. All products hazardous to health must be appropriately stored in locked facilities. Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 7 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. Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 8 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 Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 9 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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of residents have been assessed prior to their admission to the home. EVIDENCE: The individual files of a number of residents were seen, including those of recently admitted residents. It was pleasing to see that the needs of each resident had been fully assessed prior to their admission to the home. It was noted that the assessment for one resident had not been signed or dated by the person carrying out the assessment. As it is required that the assessment is carried out before admission, and by a person who is suitably qualified or suitably trained, it is recommended that this is carried out. The manager stated that local authorities support some residents financially and where this is the case, an assessment has been carried out under the care Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 10 management process. Where this is applicable, a copy of the care management assessment has been obtained and retained in the home. The manager stated that intermediate care is not provided at the home. Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and assessments of risks must be regularly reviewed and revised to reflect residents’ current and changing needs. The healthcare needs of residents are well met but the management of medication administration needs to be more robust. Residents are treated with respect and their privacy and dignity are promoted. EVIDENCE: The manager advised that the format of the individual care plans had been changed since the last inspection and that named nurses were responsible for reviewing and updating the plans. The nurse on duty would carry out any urgent changes that may be required immediately, the manager stated. As stated previously, the individual care plans for a number of residents were seen, having been sampled randomly. It was observed that the plan for one resident had not been reviewed and updated on a monthly basis as required. Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 12 This resident had recently sustained an injury requiring hospital admission, but the care plan had not been amended to reflect the resident’s changing needs. For another resident, monthly dates had been entered, but no entries had been made beside these to indicate if there were any change in the assessed needs of the resident, although it was evident that the resident has complex needs. It was also noted that assessments of risks to residents had not been completed in some cases, or updated to reflect changing levels of need. As mentioned above, a resident had been admitted to hospital following an accident, but a falls risk assessment completed five months ago had not been reviewed and revised to reflect the resident’s increased needs. A Waterlow assessment regarding risks of pressure sores, had similarly not been updated although it was clear from the daily notes that the resident was much less mobile since their accident and at increased risk of developing a pressure sore. It was pleasing to see that the care plan for one resident had been signed by the resident’s representative to signify their involvement. It is recommended that residents or their representatives are involved in the drawing up, review and revision of their care plans and sign to demonstrate their involvement. From the records seen it was clear that residents’ healthcare needs are well met. A number of healthcare professionals are involved in the support of residents including general practitioners (GP’s), hospital specialists, speech and language therapists, dentists, physiotherapists and opticians. Staff stated that medication in the home is supplied in “blister” packs or in original packs or bottles, and administration is recorded on medication administration record (MAR) charts. It is of concern that shortfalls were noted in the administration of medication. The MAR charts were seen and gaps were present in the record, so it was not possible to know if residents had received their medication as prescribed. It was observed that a small number of medications had been used in the wrong order from the blister packs. Medication was present in blisters that did not accord with the record of medication not being administered, such as when a resident was in hospital. A locked, medication fridge is available for the storage of medications requiring chilled storage and a record is maintained of the temperature of the fridge to ensure that medications are stored at the correct temperature. The record indicated that the temperature of the fridge was to be checked daily, but a number of gaps were noted on the record and only two entries had been made for December. Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 13 The amounts of medication held were sampled and for one resident this did not accurately match the record held and the records were such, that it was not possible to follow an audit trail. It was pleasing to observe that staff spoke to residents in a friendly, but appropriate manner and treated residents with respect. Staff were seen to knock before entering residents’ rooms and to await a response before entering. Assistance with personal care was provided discreetly and sensitively and staff respected residents’ privacy. Requirements have been made regarding Standards 7 and 9. Birtley House Nursing Home DS0000017594.V318655.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): 12,13,14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A wide range of seasonal entertainment and activities are made available to residents and residents are supported to be part of the local community. Residents’ preferences are respected and accommodated. A varied, wellbalanced selection of meals is offered and the meals served appeared appetising. EVIDENCE: An attractively presented programme of entertainment and activities is drawn up each month and a copy for December was supplied with the pre-inspection questionnaire and at the inspection. It was decorated with seasonal images and it was clear that a range of appropriate events had been planned. These included crafts such as making an advent ring, a Christmas collage, festive table decorations and help with Christmas cards. Other events brought the outside community into the home and included a carol concert by children from a local school, poetry reading and a visit by a local choral society, which was to accompany a finger buffet and mulled wine supper. A church minister Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 15 visits the home twice each week or on request, whilst a number of residents go out to attend churches of their choice. A visit to a local garden centre for lunch and Christmas shopping had recently taken place and residents spoke of enjoying the outing. For those residents who are less able to go out, gentle exercise to music sessions, beauty afternoons and a Christmas music and reading had been arranged. From the information supplied with the pre-inspection questionnaire it was noted that the home employs three activities co-ordinators. The co-ordinators advised that they assist residents with morning coffee and during this time, they ask residents which of the activities they wish to be involved in. Staff advised that most of the activities are carried out in the afternoons, as this enables residents to get up at a time of their choice and to enjoy leisurely mornings. Residents who were spoken with confirmed that they were offered a choice of activities and their choices were accommodated and respected. All comment cards received from residents were complimentary about the activities provided by the home. A menu was supplied with the pre-inspection questionnaire and this indicated that a range of well-balanced meals are offered. Staff advised that two main courses are provided each day, with the option of alternative dishes such as omelettes, salads or filled jacket potatoes. Meals were observed to be relaxed and unhurried, with an allocated member of staff available in the small dining room to assist if necessary. Tables were attractively set for two, three or four residents and it was pleasing to see that a visitor had joined a resident for lunch. The provider advised that it is proposed to build a larger, more accessible dining room to link with the main drawing room. Information provided in the comment cards received from residents indicate that the food is generally of a good standard. One resident stated that sometimes the food is cold. This was discussed with the manager who stated that sometimes when food is taken in bedrooms, residents do not always eat it when it arrives. The manager stated this would be monitored. Birtley House Nursing Home DS0000017594.V318655.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): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system to enable residents and their families to raise concerns. Residents are not fully protected from abuse, as not all staff have received training in adult protection issues. EVIDENCE: The home has a complaints procedure in place that includes the timescales for responding, and the CSCI (Commission For Social Care Inspection), Surrey Local Office contact details. A copy of this procedure is included in the Service Users Guide that is provided to all residents. The manager stated that copies of this procedure would be forwarded to relatives and visitors upon request. The home’s complaints and compliments book was inspected. This contained letters and cards expressing gratitude to the staff of the home and complaints received. The home has received four complaints since the last inspection, three had been resolved by the home, and one was currently ongoing. During discussions, residents stated they would make a complaint to the manager if they felt it necessary. Residents, relatives and visitors spoken to on the day of the inspection stated they had not had the need to make a complaint. Comment cards returned from residents, relatives and associated professionals confirmed they knew how to make a complaint and to whom. Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 17 It was noted in regard to one complaint dealt with by the home, and the subsequent dismissal of a member of staff, that the Protection of Vulnerable Adults procedures had not been fully followed, in that a referral to the Protection of Vulnerable Adults (POVA) list had not been made. A requirement has been made that the registered person must make a referral to the POVA list, in line with their procedures. The home has a copy of the Surrey Multi-Agency Protection of Vulnerable Adults Policy and Procedure dated February 2005. During discussions, staff gave an accurate account of the procedures to be followed in the event of a Protection of Vulnerable Adults issue. Staff stated they would not hesitate to report bad practice, and would contact the Commission For Social Care Inspection if they felt the matter had not been dealt with appropriately. It was evidenced in the record of staff training that not all staff had undertaken training in regard to the Protection of Vulnerable Adults. A requirement has been made in regard to this. Birtley House Nursing Home DS0000017594.V318655.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): 19, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides adequate communal and individual living space making it a safe and comfortable place to live. EVIDENCE: Both inspectors undertook a tour of the premises. Bedrooms were varying in sizes with appropriate furnishings, and were attractively decorated. Residents advised that they were able to bring their own personal possessions into the home, including photographs, televisions and furniture. The manager stated there is an ongoing programme of refurbishment and decoration. Some bedrooms viewed on the day of the inspection were in the process of being upgraded to improve facilities for residents. During discussions residents stated they were very happy with their accommodation. Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 19 Visitors present on the day of the inspection stated they were impressed by how clean the home is kept, and the ongoing work to keep the home looking nice and tidy. The home has laundry facilities with the appropriate settings for the prevention of spreading infection. Paper towels and liquid soap dispensers were available in all the appropriate places. Staff were observed to use personal protective equipment. From information supplied in the pre-inspection questionnaire, it was evident that the home has a contract for the collection of clinical waste. Comments included on the CSCI feedback cards inform that residents consider the home to be fresh and clean, with several commenting on the cheerfulness and hard work of the housekeeping staff. Birtley House Nursing Home DS0000017594.V318655.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): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory, ensuring staff have the qualities and training to meet the needs of residents, however, identified areas in regard to recruitment must be addressed. EVIDENCE: The staff rota forwarded with the pre-inspection questionnaire demonstrated that there were sufficient numbers and grades of staff on duty to provide care and attention to meet the assessed care needs of the residents. During discussions residents were complimentary about the staff working at the home, stating there is always someone available to help when required. Comment cards received from residents confirmed that staff are always available and listen to what you say; two comment cards returned informed that there is usually a member of staff available when you need them. From the information provided by the manager, over 50 of the care staff working at the home holds the minimum of an NVQ level 2 or above. The home has a recruitment policy and procedure dated February 2006. However, on random sampling of staff recruitment files it was evident that the home had not fully complied with Regulation 19. It is the responsibility of the Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 21 registered person to ensure the appropriate checks are conducted on staff employed to work at the care home. One recruitment file sampled did not contain two written references or a written record of explanation in gaps in employment. An immediate requirement was made in regard to this. At the time of writing this report an action plan had been received from the manager detailing the action that has been taken to comply with the immediate requirement. Other recruitment files sampled had the necessary documentation. All recruitment files sampled contained Criminal Record Bureau (CRB) reference numbers and indicated that POVA first checks had been carried out as required. Training provided during the last twelve months includes food hygiene, manual handling, first aid at work, continence and caring for patients with swallowing difficulties. However, there was no evidence of training certificates or that induction had been completed in staff training files that were sampled on the day of the inspection. A requirement has been made in regard this. Further training to be planned during the next twelve months includes refresher training for staff. Birtley House Nursing Home DS0000017594.V318655.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): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was evidence of areas of good management and practice within the home; however, some issues in regard to training, supervision and health and safety must be addressed to ensure the safety and welfare of the residents is maintained. EVIDENCE: The manager registered with the Commission For Social Care Inspection in 2006. She is a Registered Nurse with many years experience in working with older people. The manager stated she holds the NVQ level 4 in management and the Registered Managers Award (RMA). The manager stated she continues to attend training in regard to managing the care home, and that the organisation is very supportive towards her. Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 23 During discussions staff stated the manager has an open door policy, is accessible and includes staff in decision-making. The organisation has undertaken monthly audits of the home through Regulation 26 visits, copies of which are forwarded to the CSCI. The views of residents and their relatives are actively sought regarding the running of the home, through an annual survey of all residents, their representatives and visiting health care professionals. A summary of the findings was available on the day of the inspection. The manager stated that residents have a meeting every three months when discussions take place with regard to the food, activities and events happening in the home. The manager stated that all residents control their own money or are supported in this by their families, friends or representatives. During discussions with staff, the manager and sampling of staff records it was evident that staff do not receive formal one to one supervision. A requirement has been made that staff must receive formal supervision at least six times a year. The home has policies and procedures in place to aid staff in their work, which are regularly reviewed by the home. During discussions staff stated they had read and understood the policies and procedures produced by the home. It is recommended as good practice that staff sign to evidence they have read the policies and procedures. However, the inspector has since been advised that that staff sign that they have read the policies and procedures when they sign their contracts at the end of their probationary period. Information supplied to the inspector evidenced that staff had received training in regard fire, patient handling, food hygiene and some had received Protection of Vulnerable Adults training. All staff receive annual update training in regard to fire. It was observed from information provided that not all staff had undertaken training in infection control. A requirement has been made in regard to this. Two health and safety issues causing serious concern were identified during the tour of the premises. A number of fire doors were propped open with wedges and beanbags and products hazardous to health in an upstairs bathroom and in the clinical room, were not stored in locked provisions. Immediate requirements in regard to these were made. At the time of writing this report an action plan had been received from the manager detailing the action that has been taken to comply with these two immediate requirements. Information from the pre-inspection questionnaire provided evidence that health and safety records are appropriately maintained. During this inspection the following records were sampled: fire risk assessments, maintenance of fire Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 24 fighting equipment and fire drills. The last recorded fire drill was on the 5th December 2006. It is recommended that the home conduct a fire drill, not an evacuation, during the night on at least one occasion to ensure all night duty staff are familiar with the fire safety procedures to be followed. Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 25 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 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 1 X 2 Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15 (2) Requirement Timescale for action 06/02/07 2. OP7 3. OP9 4. OP18 5. OP18 The registered person must make resident’s plans of care available to residents, must keep the care plans under review and must revise the care plans when appropriate, to reflect changing needs and how these are to be met. 13 (4) (c ) The registered person must ensure that unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. 13 (2) The registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. 13 (6) The registered person must make a referral to the Protection Of Vulnerable Adults (POVA) list for the identified employee who was dismissed from their duties in line with POVA procedures. 13 (6) The registered person must ensure all staff receive training in the Protection of Vulnerable Adults. DS0000017594.V318655.R01.S.doc 12/12/06 12/12/06 13/12/06 31/01/07 Birtley House Nursing Home Version 5.2 Page 27 6. OP29 19 (1) (a) (b) Sch 2 The registered person must ensure all recruitment files have reasons for gaps in employment recorded, and two written references. Timescale of 01/09/05 has not been met. (This requirement was also made at the previous inspection and must now be complied with). The registered person must maintain a record of all training undertaken by staff, including induction training. The registered person must commence supervision, and ensure all staff receive a minimum of six formal supervision sessions per year. The registered person must ensure all staff receive training on Infection Control. The registered person must ensure fire doors are not propped open. All products hazardous to health must be appropriately stored in locked facilities. 12/12/06 7. OP30 17 (2) Sch 4 (6) (g) 18 (2) 31/01/07 8. OP36 31/01/07 9. 10. 11. OP38 OP38 OP38 18 (1) (c) 23 (4) (c) (i) 13 (4) (a) 28/02/07 12/12/06 12/12/06 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 OP3 Good Practice Recommendations It is recommended that all pre-admission assessments are signed and dated by the person carrying out the assessment, to indicate who carried it out and when it was carried out. That staff sign to evidence they have read the DS0000017594.V318655.R01.S.doc Version 5.2 Page 28 2. OP38 Birtley House Nursing Home 3. OP38 organisations policies and procedures. The organisation should conduct a nighttime fire drill to ensure night staff are familiar with the procedures to be followed. Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Birtley House Nursing Home DS0000017594.V318655.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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