Inspection on 22/04/05 for The Birches

This inspection was carried out on 22nd April 2005.

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

The Birches 24/03/09

The Birches 04/03/08

The Birches 19/07/06

The Birches 08/11/05

The Birches 17/01/05

The Birches 04/06/04

The Birches 20/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Birches 44 Hitchin Road Shefford Beds SG17 5JB Lead Inspector Dragan Cvejic Announced 22 April 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. The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Birches Address 44 Hitchin Road Shefford Beds SG17 5JB 01462 812757 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) BUPA Care Homes (Bedfordshire) Ltd Care Home 31 (31) (31) (31) Category(ies) of DE(E) - Dementia over 65 registration, with number OP - Old Age of places PD(E) - Physical Disability over 65 The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The home was located in the village of Shefford and retained very good connections with the local population. Many service users used to live in the village for a number of years prior to admission to this home. The building was purpose built and provided accommodation in 31 single rooms. The home was divided in to five units and evenly spread through the building. It offered a comfortable and homely environment with lounges in each unit. Kitchenettes in each unit accommodated those who did not want to eat in the main dining room, giving privacy in these smaller areas. The garden had a paved area accessible from the bright and sunny conservatory. It extended to a grassed, well maintained area. The home accommodated mainly elderly frail people with mild dementia. The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out in the afternoon hours during one working day. The inspection methodologies used were case tracking for 3 service users, tour of premises, 8 returned comment cards, service users’ survey results published in the home, speaking to the management structure: manager and trainee manager, speaking to 2 visitors and 8 service users. What the service does well: The home provided well written information about the home. The Statement of purpose was written in plain English and described the home so that service users could understand. On the day of the inspection, some nice classical music by Mozart was playing in the reception area. Eight service users were sitting there and welcomed the inspector. They were talking to each other and enjoyed the friendly and relaxed atmosphere. The results of a resident survey had just been analysed by the manager and showed that about 80-90 of the answers were very positive. A pond with fish was just cleaned and 2 service users and one staff member showed the inspector the beauty of their garden proudly. Two service users, who were smokers, were in the designated smoking area, in the conservatory, and said: “I get my cigarettes from staff whenever I want. I like this independence.” All service users that spoke to the inspector were proud that they could say what they wanted and were listened to. The home had a complaint procedure on their notice board and a service user commented to the inspector: “Of course I know how to complain”. The home cared for a partially blind service user who explained that he was familiar with the home and knew his way. He added that the choice of food was excellent, as he was asked to choose on a daily basis. A service user was helped to move by staff using the big hoist. He smiled and stated: “I am very happy they have got this big hoist. They help me beautifully”. The home kept organised records and notes about service users. Care plans were in service users’ bedrooms and they knew what was written down about them. The service users took part in care planning and stated how they wanted to be helped and supported, and their comments were written down. The home was well maintained. Communal areas were just re-decorated and the manager stated that the corridors would be next. The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The statement of purpose was up dated, but the address in the complaint procedure was not changed to the CSCI. A fire risk assessment had not been reviewed. The water temperature would need to be re-checked and any tap that delivered water at a higher than recommended temperature would need to be checked and adjusted by the maintenance people. The service users wanted to have some new, different activities. Writing activities on the board was useful, but some partially blind service users could not read and would need someone to read them what was planned for each day. The management would need to find a way to check and inform all staff that they follow care plans and what was written in them. The staff were quite disturbed with the investigation of a complaint that left them worried, disunited and stressed. The management arranged for frequent staff meetings to improve communication, but the home needed more help from experienced staff. There was a plan for another experienced senior member of staff to come to cover while the home’s staff were using their holidays. The staff must monitor service users whilst they are taking their medication. Please contact the provider for advice of actions taken in response to this The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5,6 The home offered sufficient information and applied an admission procedure that ensured an informed choice could be made by new service users. EVIDENCE: The home reviewed the statement of purpose, but the name of the CSCI in their complaint procedure was not updated. The statement was written in plain English and was made more user friendly. The contracts were now included in the files and copies of contracts with social services were also kept in personal files. The admission assessment was carried out appropriately and included several assessment tools, such as BASOLL and the home’s own assessment form. The home had the capability to meet the needs of service users, but there were some isolated cases where particular aspects of individual care plans were not always followed. The home offered a 6 week trial period upon admission. The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 10 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 The care plans and other records kept in the home were a good base for practical care. The home met the health care needs of service users. EVIDENCE: The care plans were drawn up from the initial assessment and were up dated frequently, in some cases monthly and in other cases three monthly. They were kept in service users’ bedrooms to allow staff direct access to relevant information. The content of care plans and daily record sheets was significantly improved since the last inspection, although the staff commented it took a longer time to write them. Individual charts for identified needs were introduced and equipped staff with this new communication tool. However, there was an example where the care plan was not followed through as expected. Medication storage, records and procedures were generally correct, apart from individual cases where the staff did not remain long enough with service users to observe and ensure that medication was correctly taken. Privacy and dignity were respected. All bedrooms had locks and lockable facilities and any service user who wanted, and was capable, would be given a key. Personal post was given to service users unopened and, when their The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 11 capacity did not guarantee that post would be handled appropriately, the home arranged for relatives to open the post with service users. The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 12 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) 12,13,14,15 The home offered a choice in terms of leisure activities, daily routine, food and personal and social relationships. Service users could voice their views, wishes and preferences and, apart from looking how to improve this area more, they were happy with the provisions and arrangements for their social life. EVIDENCE: Service users’ meetings were held once a month and their views were taken into account. The manager analysed the service users’ survey, identified their wish to expand on the existing activities and suggested this as an agenda item for the next meeting. However, the partially blind service user felt that writing information about daily activities was not sufficient for him, as he could not read. The home offered privacy in the “family room”, located on the first floor, to the service users who wanted to see their visitors in private. All service users spoken to praised the catering arrangements and the choice, quality and quantity of food. The Birches I51 s14883 THE BIRCHES v215729 220405 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 The home’s complaint procedure was effective but the risk due to unclear effectiveness of the home’s whistle blowing policy was still relatively high, especially in relation to the current complaint investigation. Financial protection was ensured by the existing procedure. EVIDENCE: The home and company’s complaint procedure was displayed and was part of the home’s statement of purpose and service user’s guide. The home had received 5 complaints. Most were resolved satisfactorily and used to improve the services and provisions. However, the complaint that was currently being investigated caused an uneasy staff atmosphere and tension in the home. Although the service users were not directly affected, the tense staff atmosphere presented a certain level of risk. The management structure had introduced certain measures to reduce and minimise this risk, by an arrangement for frequent staff meetings, emphasising whistle blowing policy and by covering the absence of senior staff, by the engagement of external senior staff from other homes from the same organisation to cover the affected periods. The investigation of complaints was delegated to external managers from the organisation to ensure a thorough, impartial investigation was carried out and collection of evidence necessary for the reaching the satisfactory outcome was complete. The Birches I51 s14883 THE BIRCHES v215729 220405 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) 19,20,21,2224,25,26 The purpose built building was well maintained, equipped and arranged in a pleasant, domestic style and offered a comfortable living environment to service users. EVIDENCE: The home’s location, state of repair, equipment and facilities met the needs of service users. The home was cyclically re-decorated. The corridors were the next item due for it, in the coming week. The home had arranged for the replacement of the rotten window frame, as was required on the last inspection. The garden was very nice, well maintained. The pond was cleaned by the their part-time cleaner and part-time carer. Shared facilities were appropriate for service users’ needs. A dining room could accommodate most service users. Three lounges provided a choice of where to sit and who to socialise with in communal areas. Bathrooms were equipped with facilities that promoted independence and ensured higher safety and comfort. Grab rails, raised toilet seats and the other equipment also helped in The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 15 meeting the service users’ needs. A service user commented that a “big hoist was beautiful” for his needs. A partly blind service user felt comfortable and safe moving around the home. Individual bedrooms were tastefully furnished and contained many elements of service users’ private possessions. All rooms had looks and a lockable facility, but no service user took up the offer of holding the key. The home was clean and bright. The natural light and ventilation ensured a pleasant feeling, not only for service users, but for staff and visitors, too. Sluice rooms were located on each floor and were away from the areas were the food was stored, processed or eaten. Infection control measures were in place and respected. The Birches I51 s14883 THE BIRCHES v215729 220405 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, 28, 29,30 The staff team were experienced, but the current complaint investigation created tension and affected the unity of the team. Communication was not well organised for all staff working in the home and created a potential risk in care process. EVIDENCE: The home had a stable rota that demonstrated who was doing what in the home. The management team assessed the needs and, through an on-call system tried to ensure extra support could be called in if an emergency situation arose. Staff commented that morale was slipping and that there were not enough staff during peak periods, and that they found it difficult to respond to all tasks at these specific times. According to the manager’s statement, the number of staff with completed, or currently attending, NVQ training was around 50 , as expected by the National Minimum Standards. Staff’s files demonstrated that the recruitment procedure was carried out thoroughly. Staff’s files contained their job application, 2 references, supervision notes, copies of proof of identity and training records and certificates. The CRB certificates were safely stored and the manager and a deputy had access to them. Training offered by BUPA, the organisation, was varied, it included mandatory topics and the home had applied for additional training covering dementia and other relevant topics to service users’ conditions. The staff expressed their satisfaction with the training programme. All new staff were inducted using the TOPSS principles. The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 17 The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 18 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) 31-38 The management was going through a difficult period trying to consolidate the staff team and regain a team atmosphere. An uneasy phase caused by the complaint investigation did not directly affect service users, but there was a high risk of deteriorating communication initiating problems in all area of life in the home, including care. EVIDENCE: The manager had applied for registration with the CSCI. She attended relevant mandatory and extra management training. She had strong support from the skilled and able deputy manager. However, the absence of any of them could affect team work. The presence of the strong top management was essential during this period of time, but the current working condition was affected by the management staff being preoccupied with more management tasks, and reduced their abilities to help with direct work with the service users. The organisation’s plan to bring in an external member of the management team was still to be implemented. The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 19 Although the style of management was open, the investigation of a complaint that required full respect of confidentiality caused an uneasy and tense atmosphere, where effective team work suffered and created a hazard to effective care work. At this point, the effectiveness of the whistle blowing policy was not proven. The internal staff’s communication was affected and did not seem appropriate. The home had a business plan. The manager and the administrator had just started processing and recording fee payments and reporting back to the head office. The manager had much more influence in the budget planning and monitoring. The survey of customers’ satisfaction was carried out and results were due to be published in May. The manager had already identified the activities as an area for further improvement, based on the initial results of the service users’ survey. Service users’ money was not held on the premises, but BUPA offered an account where the service users’ money could be safely kept and protected. The supervision process was running according to plan, but the current atmosphere dictated some changes that still needed to be applied. Current records of supervision sessions the demonstrated regularity and appropriateness of this process, for normal, day to day circumstances. Records were, in general, up to date and accurate. The temperatures of hot water needed close monitoring as one tap delivered water at higher than the recommended temperature. The fire risk assessment had not been reviewed in the last 3 years. The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 20 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 2 3 3 3 3 N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 x 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 1 3 3 3 3 3 1 The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 21 yes 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. 2. Standard 15 7 Regulation 8 15 Requirement The home must have a registered manager, as required on the previous inspection The registered person must ensure that the written care plans are implemented and reviewed and that there is a monitoring and communication system set for implementation of care plans. The administration of medication to service users must be monitored, including observing them while taking medication. The registered person must ensure that the complaint procedure contains the up to date name of the regulation authority and that the procedure is effective, timed and that complainant is kept informed. The registered person must ensure that service users are protected from any possible kind of abuse, neglect or exposure to unnecessary risk. A robust and fully effective whistle blowing policy is essential to ensure service users full protection. . The home must have competent staff on duty at any one time Timescale for action 01/09/05 01/08/05 3. 9 13 15/07/05 4. 15 22 01/08/05 5. 18 12(1)(b)( 5)(a,b), 13(4)(c)( 6) 01/08/05 6. 27 18 01/08/05 Page 22 The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 7. 32 12(5),13( 4) 8. 9. 38 38 23 23 and staff must ensure continuity of care, including at all times good communication and implementation of service users care plans. The registered person must ensure that an open, creative, inclusive and consistently appropriate atmosphere is present in the home, including good communication. The water temperature must be within specified safe range. The fire risk assessment must be reviewed and up dated regularly. 15/08/05 15/08/05 15/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Clifton House 4a Goldington Road Bedford MK40 3NF 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 The Birches I51 s14883 THE BIRCHES v215729 220405 stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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