Inspection on 04/09/07 for Birtley House Nursing Home

This inspection was carried out on 4th September 2007.

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.

Other inspections for this house

Birtley House Nursing Home 12/12/06

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 Mary Williamson Unannounced Inspection 4th September 2007 10:30 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.V346010.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.V346010.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) jackie@birtleyhouse.co.uk 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.V346010.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 12th December 2006 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 is 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 £828 to £1185. (04/09/07) Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of a key inspection and was unannounced. The inspection was carried out by Mary Williamson, Regulation Inspector over a period of six hours. The Registered Manager Jacqueline Sadler represented the service. A tour of the premises was undertaken and a number of records relating to the care of the residents and the management of the home were examined. It was possible to speak with several residents and relatives and gain feedback regarding their experience of the home. It was also possible to talk with several members of staff and discuss care practice and training. Lunch was observed to be relaxed and sociable and staff were seen to offer sensitive support to residents who required help. The art and craft group was observed during the afternoon where a group of residents were making attractive necklaces. The manager completed an AQAA (Annual Quality Assurance Assessment) prior to the inspection and there were positive comments received from residents and relatives. Equality and diversity are promoted and diverse needs of residents are recorded in individual care plans. There have been no complaints since the last inspection. The Commission for Social Care Inspection would like to thank the residents, relatives and staff team for their help and hospitality during the inspection process. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? All the requirements made at the last inspection have been met. Care plans are reviewed and reflect changing needs. Risk assessments are also reviewed accordingly. The administration of medication now demonstrates that tablets are taken in sequence from the blister pack. All the staff have received training in abuse awareness. The human resources department oversees recruitment procedures. All the employment files have been reviewed and updated. Staff training files have also been revised and are well maintained. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 7 Formal staff supervision is now taking every two months. Fire safety and COSHH procedures are now being observed. 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. The summary of this inspection report can be made available in other formats on request. Birtley House Nursing Home DS0000017594.V346010.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.V346010.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): 1, 2, 3, and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have access to the appropriate information to help them make a choice regarding the home. All prospective residents have a needs assessment undertaken prior to admission. Contracts of occupancy are in place. The home does not provide intermediate care. EVIDENCE: The home has a statement of purpose and service user guide in place and all prospective residents and their relatives have access to a copy of these prior to admission in order to help them make an informed choice about living in the home. There are also copies of these available at the main reception area. One resident said she looked at several homes prior to choosing Birtley House, and another stated that she made her mind up at the first visit. Contracts of occupancy are in place and include the accommodation offered, the care provided and the method and frequency of payment. All residents have a full needs assessment undertaken prior to admission to the home. This is undertaken by a qualified nurse in order to establish if the Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 10 home can meet the specific needs of the resident to be admitted. Four needs assessment were sampled during the inspection. These are detailed, informative and well maintained. Needs are assessed regularly. The home does not provide intermediate care. Birtley House Nursing Home DS0000017594.V346010.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 good. This judgement has been made using available evidence including a visit to this service. Individual care plans outline personal, social and emotional care needs. Appropriate arrangements are in place to meet resident’s health care needs. The medication administration policies and procedures protect the residents living in the home. EVIDENCE: Individual care plans are in place. Four care plans were randomly sampled. These plans are well written based on information gathered from the pre admission needs assessment, input from the resident and relatives, and any relevant information obtained for other health care professionals. The nursing team undertakes regular reviews of care, and care plans are updated when appropriate. Care staff were seen writing and updating information in these plans. Risk assessments are also in place and include manual handling, nutrition, Waterlow score to assess the risk of pressure sores, and for residents who require bed rails. All the residents are registered with a local GP who visits the home on a regular basis. Chiropody is organised every six weeks, and the optician visits the home yearly or more frequently if required. The manager stated that she Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 12 had recently acquired the services of a domiciliary dentist and a contract was being negotiated. The Physiotherapist visits the home twice weekly and physiotherapy can be arranged if required. There is an additional charge for this. Some residents spoken to stated “the care is excellent here”, “the nurses are very kind”, and “I am happy here”. The home has a medication policy in place. Staff administer medication in accordance with this policy, and The NMC (Nursing and Midwifery Council) Code of Professional Conduct. Medication practice was observed downstairs on West Wing unit. Boots Pharmacy supplies medication to the home in blister pack format. A record is kept of all medicine entering and leaving the home. The medication recording charts (MAR) charts were seen and are well maintained. Controlled drugs are stored in the office, and the register maintained. A locked fridge for the storage of medication is provided, and a daily record of the temperature is kept. It was recommended that photographs be provided for three residents’ medication charts to promote safety. Privacy and dignity are observed, and staff were seen to knock on residents doors prior to entering. Staff address residents in a polite and respectful manner. Equality and diversity are promoted and diverse needs of residents recorded in individual care plans. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 13 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. The home has an excellent activity programme in place. Family links are maintained and residents are supported to be part of the local community. Dietary needs are being met. EVIDENCE: The inspector was provided with the resident’s entertainment programme for September. The variety and choice of activities available is excellent. One of the company directors who is also the activities coordinator is responsible for producing this programme monthly. This is seasonal and caters for the diverse needs of residents. Two assistants support the activities coordinator. A sample of activities includes craft afternoon, beauty afternoon, tabletop games, gentle exercise, amazing stories, piano recital, charades, and music. On the afternoon of the inspection a group of residents of varying abilities were making necklaces of various colours and designs. This was followed by afternoon tea. Spiritual needs are supported and a Communion service is organised monthly in the activities room for residents and friends. Visits from various clergy can be arranged on request. A harvest festival of thanksgiving has also been arranged. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 14 Family links are maintained and visitors are welcome in the home at any reasonable time. There are facilities available for relatives to stay over if necessary and residents can also arrange for visitors to have a meal with them in the home. Residents stated that they are offered a choice of activities, which were respected and accommodated. The catering arrangements in the home are good. The chef with the input and feedback of residents plans menus. Menus offer a choice of main course for lunch each day with the option of an alternative if required. Lunch was observed during the inspection and the food offered was appetising, wholesome and nutritious. Residents were sitting in an attractive dining room in a relaxed atmosphere. Some residents were enjoying a glass of wine with their meal. The kitchen was visited and the chef spoken to. There was an agency chef on duty that was covering for special leave and annual leave. The kitchen was well managed, clean and orderly. All staff that handle food hold a food hygiene certificate. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. The complaints and the abuse awareness policies in place protect residents living in the home. EVIDENCE: The home has a complaints procedure in place. All residents and relatives have a copy of this procedure, which also forms part of the service user guide. The complaints log was seen and there have been no complaints since the last inspection. A folder of compliments and thank you cards is also retained in the home. Residents and relatives spoken to said that they would make a complaint to any of the directors or manager if it was necessary, and felt confident that this would be resolved. The home has an abuse awareness procedure in place and all staff undertake training in abuse awareness during their induction training. During discussion with staff they were aware of this procedure and stated that they would not hesitate to report suspicion of abuse. The home has a copy of Surrey’s Multi-Agency Policies and Procedures on Safeguarding Vulnerable Adults in place and the manager stated that she and senior members of the management team had attended the local authority training provided. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 16 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, 20, 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 is suitable for its stated purpose providing residents with a good standard of communal and individual of accommodation, which is comfortable and well maintained. The standard of cleanliness is excellent. EVIDENCE: A tour of the premises was undertaken. There are ample communal areas provided including lounge and dining areas. A large drawing room overlooks a well- maintained rose garden. The view from all the communal areas is attractive overlooking well-maintained grounds including a lake. Some of the residents invited the inspector to view their rooms. These vary in size and all are decorated and furnished to a high standard. Residents can bring items of furniture and personal possessions with them into the home. Residents spoken to said they were satisfied with the accommodation provided. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 17 The standard of housekeeping and cleanliness in the home is excellent. It was possible to speak with the housekeeper who outlined her role and responsibilities. She manager a team of staff including cleaning staff, laundry staff and kitchen assistants. Comments received from relatives stated that the home was always clean and one resident stated that her room was always “cleaned well”. The laundry is well equipped and meets the requirements of the home. There is an infection control policy in place and all staff have training in this policy. Arrangements are in place for the collection of clinical waste. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 18 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, 28, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff on duty are sufficient to meet the assessed needs of the residents. Residents are protected by the home’s recruitment procedures, and training programme. EVIDENCE: The staff duty rota was seen and discussed with the manager. The number of staff on duty was sufficient to meet the assessed needs of the residents in the home. Staff were observed throughout the day going about their duties in a professional and confident manner. They were seen to answer call bells efficiently and offer sensitive support when required. Residents commented that the care provided in the home was good, and “the staff are very kind”. Several relatives also made similar comments. Staff have training and development programmes in place. All staff undertake induction training in the form of a work sheet, which is signed on completion. Training files indicated over 50 of staff either have achieved or are working towards NVQ Level 2. Two staff received their NVQ certificates on the day of the inspection. The training and compliance manager was facilitating a training day during the inspection on food safety and fire safety. Staff were spoken to throughout the day and confirmed some of the training they had undertaken and gave positive feedback about working in the home. An agency member of staff stated that the agency provided her with all the mandatory training, and that the home introduced her to the essential health and safety procedures. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 19 The recruitment procedures in the home were explored. Three staff employment files were randomly sampled. These are well maintained by the human resource department and contained all the required documentation for employment legislation, including two written references, an employment history and a CRB (Criminal Records Bureau) disclosure number. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 20 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, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed in the best interests of the residents. The health, safety and welfare, of the residents are promoted. EVIDENCE: The home is well managed by an experienced manager with several years experience in the provision of care to older people. She is also a qualified nurse and has the Registered Managers Award (RMA). Two senior sisters and a team of qualified nurses support the manager. There is also a group of four company directors, who provide an administrative role to oversee the smooth management of the home and the estate. Residents stated that there is always a senior manager available if they wish to discuss a problem. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 21 Systems are in place for the effective monitoring of quality assurance. Regulation 26 visits take place monthly and reports retained in the home for inspection. Quality assurance survey forms are sent to residents, relatives, and health care professionals for comment. Feedback is analysed and a report compiled with results available in the home’s newsletter. All issues arising are addressed. Residents meetings, staff meetings, medication audits, care plan audits, and management meetings also take place and may be used for quality assurance purposes. The manager stated that the home does not manage financial transactions for residents. Some residents are in control of their own financial affairs, while others have their relatives or a designated representative manage their financial affairs on their behalf. The home has a wide range of policies and procedures in place and a selection of these were seen throughout the inspection. Staff have training in health and safety which includes, manual handling, food hygiene, fire safety, and first aid. The fire safety arrangements in the home are satisfactory. There is a contract in place for the maintenance of fire fighting equipment and emergency lighting. Regular fire drills are undertaken. Information provided in the AQAA indicated that all the required certificates of safety are in place. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 22 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations It is recommended that a photograph be provided in the front of three medication recording charts for identification purposes, as discussed with the manager. Birtley House Nursing Home DS0000017594.V346010.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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.V346010.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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