Inspection on 15/11/05 for The Birches

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

The Birches 17/05/07

The Birches 02/02/06

The Birches 27/09/04

The Birches 26/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 The Birches Grammar School Road Brigg North Lincolnshire DN20 8BB Lead Inspector George Skinn Unannounced Inspection 15th November 2005 09:30 The Birches DS0000002811.V262117.R01.S.doc Version 5.0 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 The Birches DS0000002811.V262117.R01.S.doc Version 5.0 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 Adults 18-65. 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. The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Birches Address Grammar School Road Brigg North Lincolnshire DN20 8BB 01652 652348 01652 653803 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) HICA Miss Michelle Lawes Care Home 31 Category(ies) of Learning disability (31), Learning disability over registration, with number 65 years of age (31) of places The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2004 Brief Description of the Service: The Birches is purpose-built accommodation situated in the town of Brigg. It provides personal care and accommodation for up to 31 adults with a learning disability in both categories of younger people and over 65 years. The home is owned by HICA Specialised Care Homes. The accommodation is provided in three eight-bedded bungalows, one four-bedded bungalow and two self-contained flats. Each bungalow has its own bathroom, shower room, toilets and living/kitchen area providing domestic facilities and equipment. All bedrooms are single rooms and all but two have en-suite facilities. The bedrooms without en-suite have a hand washbasin provided. A central core building contains offices, main kitchen, central laundry, meeting room, sensory environment and a lounge. There is a large garden area with well-tended lawns and parking to the front of the building. The home has its own mini bus. The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took 5 hours. The home was measured against the National Minimum Standards for Younger Adults. Residents were spoken with, the building was inspected and some records were looked at. What the service does well: What has improved since the last inspection? 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 Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Residents are assessed prior to moving into the home and know their needs and aspirations will be met. EVIDENCE: Residents are only admitted to the home having undergone an assessment by either by the Local Authority or senior staff from the home, thus ensuring that the home can meet their needs. In addition to the pre admission assessment, the home undertakes a further assessment of strengths and needs once the resident has arrived. It is on the basis of both these assessments that the resident’s plan of care is formalised. Evidence seen indicated that the residents are involved in this process. Risk assessments are produced for restrictions on choice, freedom, service or facilities. The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 Residents changing needs are well managed. Taking risk is seen as part of the resident’s choice in how they wish to live their lives. EVIDENCE: From discussion with residents, it is clear that they are provided with information, assistance and support to make decisions about their lives and this was documented in care plans. Residents gave examples of being able to make real choices in their daily activities and there was evidence that they attended their own reviews. Where others make decisions on behalf of the residents, staff are able to demonstrate why these decisions have been made and explain to the resident the reasons. Limitations on choice are only made in the resident’s best interests. Where possible, residents are encouraged to maintain their own finances; others finances are handled by relatives. The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 9 The key worker system and residents’ meetings enabled residents to be involved in wider decision making. Details of advocacy services are included in the ‘Resident Guide’. Residents are enabled to take responsible risks as part of an independent lifestyle. Risk assessments are in place and on occasions are signed by them as confirmation that they are aware of the need to minimize risk. Residents’ representatives signed all risk assessments. Action is taken to minimize identified risks without limiting residents preferred choices. The home has a missing persons procedure. The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 16 & 17 Residents are part of the local community and are enabled to take advantage of local facilities; they are offered a balanced and healthy diet and enjoy their meals. EVIDENCE: Residents are part of the local community; this is achieved by involving the residents in local activities and by the pure nature of the home’s location. Local shops, public houses and places of worship are visited. The inspector was informed that all residents are on the electoral register. Local taxis are used for transport to social clubs, outings, etc. The home provides residents with a varied, appealing, wholesome and nutritious diet and, as a result, has obtained the Heartbeat Award. The staff that are responsible for serving the meals know residents’ likes and dislikes. Residents spoke positively about the quality of the meals making The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 11 comments which included, “the food is always nice” and “there is always a good choice”. Residents are offered a choice at each mealtime; the menu indicates that cooked alternatives are available at teatime. The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Residents felt their views are listened to, valued and acted on. The residents are protected from abuse. EVIDENCE: Residents knew whom to approach if they had any complaints or concerns and they were sure these would be taken seriously and acted upon. A complaints procedure is available which encourages residents and relatives to express their dissatisfaction without fear of repercussion. This procedure includes contact details for CSCI. Complaints are seen as an opportunity to improve the service as a whole or more specifically for an individual. Residents are protected from abuse with robust procedures in place for responding to any suspicion. All staff receive formal training on abuse and the protection of vulnerable adults. The employee handbook also outlines details of the home’s POVA policy. Whistle blowing is incorporated in the communications policy and in POVA training. Policies and procedures were in place regarding handling of aggression and the use of control and restraint is not permitted. The home has a detailed system for the management of residents’ finances, which protects residents from financial abuse. The home’s policies and procedures preclude staff from involvement in the making of wills or receiving gifts. The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Residents live in a home which is comfortable, safe and free from offensive odours. EVIDENCE: The home had policies and procedures in place for infection control and disposal of clinical waste. The building was clean and free from offensive odours on the day of inspection. The main laundry facility was sited away from food preparation and storage areas. The laundry floor was impermeable and the walls were washable. Hand washing facilities were provided, and personal protective equipment was provided for staff. Washing machines had a disinfection programme and services and facilities complied with the Water Supply (Water Fittings) Regulations 1999 eliminating the risk of cross infection. The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Residents are protected by the recruitment process for new staff. EVIDENCE: The organisation has a detailed recruitment procedure. As part of this inspection three random staff files were seen. From these files it was evident that two references were sought. CRB checks are undertaken along with a health assessment. A copy of the General Social Care Code of Conduct is made available to staff. All staff are provided with written terms and conditions within 8 weeks of employment and copies of these are retained at headquarters. The organisations policy and procedures regarding the recruitment of volunteers outlines a thorough process, which includes the obtaining of references and a CRB check, the home does not currently have any volunteers. Evidence seen indicated that a copy of a passport and birth certificate is obtained as part of the recruitment process and these documents had been seen for CRB purposes. The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The health and welfare of the residents is protected. EVIDENCE: The home had a detailed health and safety policy. Safe working practices were maintained by the provision of mandatory training and service specific training. Systems were in place to ensure that the maintenance of the building and equipment was up-to-date. Environmental risk assessments had been completed and all accidents were logged and monitored. COSHH sheets had been obtained for products used at the home and the products were stored safely. A fire risk assessment had been undertaken. Records showed that the fire detection and alarm system had been serviced. Fire drills took place monthly. Emergency lighting checks are undertaken 6 monthly. The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 17 Water temperatures at outlets accessed by residents are regulated and checks are regularly made. The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 Score 4 4 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 3 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x x x 3 4 x CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Birches Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x DS0000002811.V262117.R01.S.doc Version 5.0 Page 19 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. Refer to Standard Good Practice Recommendations The Birches DS0000002811.V262117.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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