Inspection on 13/06/05 for Sue Ryder Care Birchley Hall

This inspection was carried out on 13th June 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.

Other inspections for this house

Sue Ryder Care Birchley Hall 04/12/07

Sue Ryder Care Birchley Hall 08/01/07

Sue Ryder Care Birchley Hall 19/07/05

Sue Ryder Care Birchley Hall 09/12/04

Sue Ryder Care Birchley Hall 24/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sue Ryder Care Birchley Hall Birchley Road Billinge Wigan WN5 7QJ Lead Inspector Lynn Paterson Unannounced 13th June 2005 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. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sue Ryder Care Birchley Hall Address Billinge Wigan WN5 7QJ 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) 01744 894893 01744 895430 Sue Ryder Care Mrs Des Reynolds Care Home 30 Category(ies) of Dementia (2) registration, with number Old Age (30) of places Physical Disability (30) Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include up to 30 (OP); 30 (PD) over the age of 55 years; 2 (DE) That staff are provide in sufficient numbers and skills mix to meet the assessed needs of all service users. Date of last inspection 09/06/04 Brief Description of the Service: Birchley Hall Care Home is registered to accomodate 30 older persons who are in need of assistance with their personal and social care.The home forms part of The Sue`Rider organisation and is situated in a residential area close to shops and local amenities and is set within extensive grounds affording views over open countyside.The premsises comprise 24 single and 3 double bedrooms, of which have ensuite facility. Accomodation is provided over 3 floors with upper floors being accessible via a passenger lift. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a four and a half hour period. The manager and her deputy were not available within the home due to other commitments therefore the inspection was carried out with the assistance of the care supervisor. For the purpose of this report a full tour of the premises took place and 25 of the 30 residents, 9 of the staff on duty, the home support manager and 2 visitors to the home were spoken with. Care files, policies and procedures, records and other documentation were examined as part of the inspection process. What the service does well: What has improved since the last inspection? The home has had a conservatory added to the dining area of the home and residents expressed pleasure at having the extra seating facility overlooking the grounds. A maintenance/building support manager has recently been appointed to manage and oversee general maintenance, ground work, cleaning and laundry duties and all relevant records seen were well managed and recorded. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 6 Records showed that staff received ongoing training in care management and have now added optical care to their training programme. 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. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 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 Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 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) 3 Pre admission procedures were in place to ensure that an assessment was carried out on prospective residents with a view to identifying that the home could meet assessed need. EVIDENCE: Three care files were examined and details on file revealed that the residents had been assessed prior to admission and all assessed need had been recorded on file. Care plans held information that showed that the assessed needs had been identified and planned for. Staff spoken with exhibited full knowledge of assessed need and of the practices involved in meeting assessed need. Staff advised that they had access to pre admission details to ensure that they had a clear overview that the home could provide care and aids and adaptations appropriate to the needs of the individual. The full process carried out was seen to be of a high standard. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 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) 7.8.9.10. Care planning methods ensured that health, personal and social care needs were identified, recorded, planned for and carried out in a professional and respectful manor by staff that had received training to provide quality care. EVIDENCE: Care plans viewed revealed that all health, personal and social care needs were recorded, monitored and reviewed as appropriate. The care plans were easy to read and gave full details about the assessed care need and of how the resident wished the care to be given. Care plans held full information relating to medical records, health promotion, skin care and risk assessment. Residents spoken with said that they were happy with the way they were looked after and comments received included” the staff treat us very well”, “staff are always respectful to us”, “staff `are kind an helpful”, “nothing is too much trouble for the staff here”,” We could not say a bad word about the staff or the home as it is all so good”, ”staff seem to know what care `is needed for us all”. Staff spoke with identified that they had received on going training in care practices, which had provided them with a sound knowledge and understanding of care provision to include issues relating to respect, privacy and dignity. Training records held information to show that staff who administered medication had received full training in medication management Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 10 and medication records and storage viewed were of a good quality at the time of the visit. Staff training records further evidenced that staff had received training in optical care, health promotion, risk assessment and pressure care. The overall care planning process was of a high standard. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12.13.15 Social activities and outings provide daily interests for residents and assist residents to maintain contact with the local community. Menus are wholesome, appealing and are drawn up in consultation with residents. EVIDENCE: Discussions with residents revealed that they were happy with the general activity and interests within Birchley Hall .An activity programme was available on the notice board in the lounge of the home and also provided on each table in the dining room as a reminder to residents as to what was happening each day. Activities included Bingo, sing a-long’ exercise classes and outings to include visits to the local community social events. Minutes from the recent residents meetings, item 3, held details of residents making contributions to the activities and outings programme and residents said that they were generally happy with the events that took place within the home. One resident said that she had participated in the past in chair line dancing and she said that she would mention this to the staff to see if this could be added to the activities programme at Birchley hall. Minutes of the residents meeting, item 4,revealed that menus were also discussed and residents were asked to contribute their ideas for menus. Residents spoken with said that the food provision was of a high quality and choices were always available and comments included “we could never complain about the food in here”, ”the food is always well prepared and tasty” Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 12 ”we are asked if we want to add anything to the menu”,” we are given choices at all mealtimes” ”the food is lovely”. Observation of the residents eating lunch in the dining room indicated that the residents were enjoying a well prepared, nourishing meal in most pleasant surroundings. The home records showed that Birchely Hall staff encouraged residents to maintain contact with their families and the wider community and trips and social activities are arranged to facilitate this. The home have a community bus which is used for the benefit of the residents and is used for outings to events and places of interest and staff advised that all residents are given the opportunity to enjoy” trips out on the bus”. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16.18 Staff and residents are confident that their complaints would be handled in a sensitive and dignified manor and would be dealt with quickly as per company policy. The home has a vulnerable adults procedure in place to ensure that appropriate action is taken in response to suspicion or allegation of abuse. EVIDENCE: The complaints procedure in the home was clear and identified the full process of making, receiving, recording and investigating complaints. The complaint records in the home showed that no complaints had been received since the previous inspection. Residents spoken with said that they knew how to complain and were asked by staff on a daily basis if everything was to their liking. Residents further commented that they had no reason to complain as they felt that the home provided a very good service. Staff advised that they had received training in adult protection and were fully aware of the process involved in how to identify and respond to any suspicions or allegations of abuse. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 14 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) 19.26. The home has an ongoing redecoration and maintenance programme and observations and maintenance records showed that the people living in Birchley hall are provided with safe, secure, comfortable surroundings. EVIDENCE: The home has employed a support manager who in discussion advised that he has responsibility for the building and ground maintenance and also for the management of laundry and domestic staff. The home has continued with refurbishment and redecoration since the previous inspection to include the provision of a new conservatory situated behind the dining room and gazebos placed within the front garden area of the premises. Residents said that the home was well maintained and was always clean and tidy. The general appearance of the home is good and all essential services have records to show that they are serviced and managed as appropriate. Records showed that building risk assessments are carried out by staff to ensure that residents live in a safe and well- maintained environment. A tour of the premises revealed that the home provided hand rails, hoists, bathing aids, specialist seating and dining facility and a secure passenger lift for ease of Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 15 access to all areas of the home. It was noted that domestic staff were low in numbers due to staff absence however the home was clean, tidy and free from unpleasant smells at the time of the visit. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 16 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) 27.30 Staff are provided in sufficient numbers and skill mix and receive relevant ongoing training to ensure they are fully competent to meet the assessed needs of the residents of Birchley Hall. EVIDENCE: Staff spoken with stated that they had received training in care practices and had full knowledge and understanding of how to provide well planned care for the residents. Residents said that staff were kind, considerate and treated them well. Residents comments included “staff are always helpful”, “we know that they will look after us properly”,” they know how to look after us all”. Observations of staff and residents revealed good interactions and the exchange of gentle humour and residents said that the atmosphere in the home was one in which they felt safe and supported. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 17 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) 35 Residents financial interests are `safeguarded. EVIDENCE: Records relating to residents finances were well -maintained and held full details of financial transactions. Records viewed held double signatures and were stored in a secure locked office and were accessible only to the finance officer and the individual resident or resident’s representative. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 18 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 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 4 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x x x Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 19 no 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. 1. 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 30 Good Practice Recommendations It is recommend that staff receive training in dementia care to meet the changing needs of the residents of Birchley Hall. Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 2nd Floor Burlington House Crosby Road North Waterloo L22 0LG 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. Extracts may not be used or reproduced without the express permission of CSCI Sue Ryder Care Birchley Hall F53 F03 S22399 Sue Ryder Care V233998 130605 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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