Inspection on 04/03/08 for The Birches

This inspection was carried out on 4th March 2008.

CSCI found this care home to be providing an Adequate service.

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 19/07/06

The Birches 08/11/05

The Birches 22/04/05

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 Bedfordshire SG17 5JB Lead Inspector Nicky Hone Unannounced Inspection 4th March 2008 10:20 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 The Birches DS0000014883.V360477.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. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Birches Address 44 Hitchin Road Shefford Bedfordshire SG17 5JB 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) 01462 812757 01462 812264 holmesch@bupa.com BUPA Care Homes (Bedfordshire) Ltd Miss Christine Helene Holmes Care Home 31 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (31), of places Physical disability over 65 years of age (31) The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2006 Brief Description of the Service: The Birches is situated near the main road through the village of Shefford, and is on a bus route. Village amenities such as local shops, pubs and so on are within walking distance. The home retains very good links with the local population, and many of the residents used to live in the village. Purpose-built in the 1960s, The Birches offers accommodation on two floors to thirty-one older people. The home has several lounges and other seating areas such as in the entrance hall, and one large dining room. Each lounge has a kitchenette area where staff and residents prepare drinks and snacks. There is a smoking room, main kitchen and laundry as well as bathroom and toilet facilities. A conservatory/lounge leads into the landscaped garden which provides pleasant seating areas in the warmer weather. The fees for this home, at the time of our visit, were in the range of £410 to £580. In the entrance hall there is a table which holds a range of information for people, including CSCI’s latest inspection report. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. For this inspection we (the Commission for Social Care Inspection) looked at all the information that we have received, or asked for, since the last key inspection of The Birches. This included: • The AQAA (Annual Quality Assurance Assessment) that the manager completed and sent to us in August 2007. The AQAA is a selfassessment that focuses on how well outcomes are being met for people living at the home. It gives the manager the opportunity to say what the home is doing to meet the standards and regulations, and how the home can improve to make life even better for the people who live there. The AQAA also gives us some numerical information about the service; Surveys which we sent to people who use the service, to their relatives/carers, and to staff. We received a total of twenty two replies. Some of the comments from the surveys, and some of the results are quoted in the summary and in the body of the report; and What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • • This inspection of The Birches included an unannounced visit to the home on 04/03/08. The manager was not on duty on the day we visited, but the deputy manager assisted us competently throughout the inspection. We spoke with several of the people who live at the Birches, some of the staff, and the deputy manager. We looked at some of the paperwork the home has to keep. This included assessments, care plans, medication charts, and records such as staff personnel files, rotas, menus and fire alarm test records. We want to thank the residents and staff for their time, and assistance during our visit. What the service does well: From the responses we received to our survey, generally people are happy with the service that is being provided. One person told us “The home is The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 6 lovely”; 2 people said they are “very happy”; and two people wrote “there is no need for the home to improve”. One person we spoke with said “All the staff are lovely”. Another person wrote “the staff are good at caring for us”. One of the staff who responded to our survey wrote “very good home to work for”. Another wrote “we are basically a good home…..we try to make sure our residents know that we care about them”. In the AQAA the manager said she knows the home does well because “All visitors including professionals comment on the pleasant atmosphere and the homely environment. Complimentary cards, letters and flowers. Respite residents who have become permanant because they have specified the desire to be placed at The Birches. Positive customer satisfaction surveys.” On the day we visited the atmosphere was indeed very pleasant. The home felt welcoming, warm and friendly, there was a gentle buzz of conversation all day in the lounges and entrance hall, and in the dining room at lunchtime, and residents and staff seemed to get on very well with each other. Residents feel they are treated with respect and dignity, and they know their concerns will be listened to if they raise any. Residents are encouraged to maintain links with their family and friends, and with the local community. Visitors are always made to feel welcome at The Birches. Meals are good and appreciated by everyone. Menus are varied and offer a nutritios diet. Mealtimes are relaxed and are a pleasant experience for all. There are usually enough staff on duty, many of whom have worked at The Birches for some time. I staff member, who could have retired, told us she “couldn’t give it up”. A range of training takes place for staff, and several have been awarded a National Vocational Qualification (NVQ) in care. The majority of records the home has to keep are maintained well, and health and safety is given high priority. What has improved since the last inspection? New paperwork has been introduced for residents’ needs to be assessed and this is done well. The assessments, along with risk assessments about specific areas of care, lead to care plans. On the whole guidance for staff in the care plans was satisfactory. In the AQAA the manager listed a number of areas where she feels the service has improved, including quarterly resident meetings and newsletter, menus and mealtimes, reduction in agency use and staff training. Much of the home has been redecorated since our last inspection. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 7 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. The Birches DS0000014883.V360477.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 The Birches DS0000014883.V360477.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, 3, 6 People who use this service experience good quality outcomes in this area. People can be confident that their care will be based on good information the home has about them. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The statement of purpose and service user guide are regularly updated, and copies are displayed in the entrance hall, along with BUPA information. Each of the people who live at The Birches has a copy of the service user guide in their bedroom. For this inspection we looked at the information the home holds on four of the people who were living at the home on the day we visited. One of these people was at the home for a respite stay, and one was the newest resident. On the files we found that an assessment of the person’s needs is carried out The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 10 by a social worker before the person’s name is put forward for a place at the home. The home’s staff also carry out an assessment. The deputy manager explained to us that BUPA had introduced some new assessment paperwork towards the end of 2007, and staff had carried out a completely new assessment of the needs of each of the residents. We saw these on each file, and all gave full and detailed information. In the AQAA the manager told us that all new residents are invited into the home for lunch or tea, are shown round, and encouraged to ask any questions. Intermediate care is a service offered by some homes, which gives short-term, intensive rehabilitation for people leaving hospital before returning to their own homes. This service is not offered at The Birches, so standard 6 does not apply. The Birches DS0000014883.V360477.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, 10 People who use this service experience adequate quality outcomes in this area. Care plans can still improve further so that there is evidence that people receive the care they want and need. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Each person has a plan of care based on the assessments that have been done, and these are reviewed monthly to two-monthly. A care plan for an individual aspect of care (for example bathing, eating, walking and so on) is written when the assessment identifies it to be necessary. We also saw that manual handling and falls assessments are completed, and so is a ‘falls diary’ and a pressure sore risk assessment. Of the 8 people who responded to our survey, when asked ‘do you receive the care you need?’ 7 people ticked ‘always’, and one ticked ‘sometimes’. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 12 The assessment/care plan of the person who was at the home for a respite stay had been written when he last stayed at the home, and we saw that it had been reviewed when he arrived this time for his stay. All plans for identified areas of his needs were in the file. We noted on two people’s files that the plan for eating/drinking had been reviewed and a weight loss had been identified. For one person the loss had been reported to his doctor and he was now gaining weight. The assessment the home uses stated that a loss of more than 5 of a person’s weight in 6 months should be considered a high risk and reported to their doctor. We discussed with the deputy manager that the second person had lost 4.75 in two months, which is a very high rate of loss, and we felt more action could have been taken. One person’s plan relating to ‘mental state/cognition’ gave a good description of the problems but guidance for staff on how to deal with the problems was not adequate. We saw no evidence on any of the plans we looked at that the person and/or their family had been involved in writing or reviewing the plan. The deputy manager agreed that this could be achieved within 3 months. The home has a good relationship with the local doctor, who visits the home weekly, and with district nurses who visit at least twice weekly to support the staff with any nursing tasks. One person was quite unwell when we visited: the district nurses had arranged for a special bed and mattress to be delivered. All 8 people who responded to our survey said they always receive the medical support they need. Other healthcare needs are met. For example, people can choose to have NHS Footcare when it is available (approximately 3-monthly), or see a private chiropodist who will visit whenever needed. Families arrange dental appointments if people need them, or a local dentist will visit the home. As with the chiropodist, people have to pay for this themselves. A mobile clinic visits the home regularly to offer optical services to anyone who wants them. A hairdresser works in the home’s hairdressing salon twice a week, and a barber visits the home every six weeks to cut the men’s hair. Staff complete ‘daily life’ notes about each person. These were very brief and gave limited information about the person’s daily life. The notes we saw contained very little about any activities the person might have been doing, and gave no indication of whether any instructions on the care plan had been followed. For example, one person’s care plan gave instructions to staff “to check inside X’s mouth”, but this was not mentioned on the daily notes, so there was no evidence of whether it had been done. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 13 We saw that staff and residents have very good relationships. They were friendly and caring towards each other and there was a strong feeling of mutual respect. Residents who responded to our survey said staff treat them well. We were told that The Birches had changed to the Boots monitored dosage system of medication 5 weeks before we visited. New cabinets, trolleys and a locked medication fridge had been provided: all were neat and tidy and contained a suitable stock of medicines. The deputy manager told us that medicines are only administered by team leaders, managers and night staff, all of whom have had medication training. She said that Boots have done some training recently, and she did a ‘Safe Handling of Medicines’ course some years ago. The deputy manager said she teaches the staff and assesses their competence. We asked her to check with the CSCI pharmacist whether she is suitably qualified to be sure that staff are trained properly. Generally, this home handles medicines well. We saw that photocopies of the prescriptions are kept; there is a photograph of each person on the Medication Administration Records file; all medicines had been counted in, signed and dated; and all oral medicines had been signed for when they were given. However, there were a number of gaps in the record of the administration of topical medication (creams). For example, for one person there were 7 boxes initialled, and another 5, when there should have been 17 each. The deputy manager agreed that this is an area where the staff struggle to keep the records correctly. Eye drops were in the locked fridge and were correctly dated when they were opened. The fridge has a maximum and minimum thermometer, visible when the door is locked. Staff had recorded these temperatures daily up to 20/02/08, and all were within the correct range. The deputy manager did not understand why the staff had stopped recording the temperature and said she would make sure daily recording started again immediately. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People who use this service experience adequate quality outcomes in this area. There is not enough for residents to do to keep them occupied and their minds stimulated. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home employs someone for 5 hours a week to lead on activities for the residents. The deputy manager told us that this person mainly does arts and crafts. In the AQAA the manager wrote that another 5 hours for activities had been put into the plans, but the deputy said this had not been given to the home in this year’s budget so the additional 5 hours would not be available. In the AQAA, completed in August, the manager said a new activity programme covering 5 days a week had been introduced. However, this seemed to have lapsed by the time of our visit. A church service is held in the dining room on 2 Sundays a month, and a bingo session takes place weekly. There have not been any outings for residents for The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 15 quite some time. One person we spoke to about outings said “they don’t do that – I wish they would really”. Newspapers are delivered daily. One person prefers to walk to the local shop to buy his own paper, which is encouraged by the staff. The home has 3 cats, and the deputy manager takes her dog to work: residents told us they love to have the animals around. During our visit a member of staff brought her baby granddaughter in to visit the residents. In our survey we asked the residents ‘Are there activities arranged that you can take part in?’ Of the 8 people who replied, 5 wrote ‘always’ and three wrote ‘usually’. One of the 8 relatives and three of the six staff who completed surveys said there should be outings for residents, even if just going to the local shop in a wheelchair. The deputy manager told us she felt that this area of care, that is activities and outings, is one in which the home “could do better”. There were very few entries in daily notes about activities of any sort. Following our last inspection we made a requirement that the home must “…consult service users and devise a programme suitable for users’ abilities and preferences”. We could not find any evidence that this has been met, so will be a requirement again this time. People who move into the home are encouraged to retain links with their families and with the local community. Families are made welcome and are encouraged to visit at any time. There is one large dining room at The Birches. Residents can choose to eat in any of the sitting areas, or in their bedrooms, but the majority choose to eat together in the dining room. Tables in the dining room were nicely set for lunch, with table cloths, cutlery, glasses, serviettes and salt and pepper on each table. Lunch was served through a hatch from the kitchen. Residents have a choice of two main meals for lunch. One person told us that “the cook comes round and asks us what we want for the next day, but we can change when we get to the table”. We saw that vegetables were put on each table in serving dishes, for residents to help themselves. Everyone was offered a choice of drink with their lunch, and those who needed or wanted one were given a tabard clothes protector to wear. It was good to see that staff made sure that each person at the table was given their main meal, assisted with vegetables if they needed assistance, and had everything they needed before the staff moved on to serve the next table. One person had to leave the room during the meal: the staff immediately took his dinner to keep it hot for when he returned. People who needed assistance with their food were given it in a very calm, thoughtful way, and each person was able to eat their meal at their own pace. Residents were chatting to each other and to the staff, and the whole mealtime was relaxed and friendly. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 16 We looked at the menus. Each day there is a choice of main meal and a choice of dessert, with a good variety of dishes being offered. People we spoke with said the food is very good. The meal we saw served on the day of our visit looked appetizing and nourishing, and people enjoyed eating the meal. One person said he buys lots of fruit and keeps it in his bedroom. 7 of the 8 people who responded to our survey said they always like the meals, and one said usually. The chef has worked at The Birches for about 3 months, and has gradually been improving all aspects of her job. She has worked on changing the menus and told us she is introducing a menu manager system where all menu items are scored, and each meal has to attain a minimum score to ensure proper nutrition. Each home must keep a record of food provided: The Birches was not doing this, but the cook agreed to find a way. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 17 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, 18 People who use this service experience adequate quality outcomes in this area. Residents of The Birches and their families know that their concerns will be listened to and dealt with, but not enough staff have had safeguarding training to be sure residents are kept safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The complaints procedure was displayed clearly on the wall in the entrance hall to the home, and was in the service user guide in each person’s room. The deputy manager showed us the complaints log where all complaints are recorded. Two complaints had been received and both had been responded to appropriately. One person said he would feel comfortable talking to any of the senior staff if anything was wrong. One person who responded to our survey wrote “No need to make complaints because everything runs smoothly”; and another “Just haven’t got any complaints”. In the AQAA the manager said that there has been a reduction in the number of complaints, and an increase in the number of compliments that the home has received in the previous 12 months. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 18 According to the deputy manager, most of the staff have had “Abuse in Care Homes” training. This is a video and was presented to the staff by the manager. In the AQAA the manager said that POVA (Protection (safeguarding) of Vulnerable Adults) is discussed in staff meetings, but admitted that this could be “re-visited” so the home deals with it better. The training records we saw showed that 10 staff have not done a safeguarding course. The deputy manager said that new staff cover safeguarding in their induction. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 19 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, 21, 24, 25, 26 People who use this service experience good quality outcomes in this area. The Birches is attractively decorated, comfortably furnished and has a really warm, homely atmosphere which gives the residents a pleasant home to live in. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The deputy manager told us that two lounges and two corridors had recently been redecorated, as well as 5 of the bedrooms. We walked round the home and generally all areas are well-maintained. Some minor defects, such as some scuffing on doors and door-frames from wheelchairs, and the paintwork on the main staircase were discussed with the deputy manager. She explained that all the decorating allowed in this year’s budget has been completed. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 20 We saw some of the bedrooms. Bedrooms which used to be double rooms are a good size, but the original single rooms are quite small. However, most of them are suitable for the people who live in them, and all had been made as personal as possible to the occupant. Most of the bathrooms were very attractive, with stencilling on the walls, pictures, flowers, curtains and other homely touches. All the lounges were comfortably furnished and everywhere was very clean. We saw one commode which was tatty and could be a hygiene risk, and a couple of bedrooms had an unpleasant odour of urine. We were told that the only walk-in shower does not work as the water pressure is not good enough: this is a shame for people who might prefer a shower. The garden at the rear of the home was well-maintained. The deputy manager explained that this is done by a contractor, except for one large flower bed which is looked after by the relative of someone who used to live at The Birches. This bed was very attractive and full of brightly coloured flowers. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People who use this service experience good quality outcomes in this area. People who live here know that usually there are enough staff to meet their needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: One of the residents said “The staff seem to cope alright, in fact they do very well and they’re very nice”. One member of staff said she had worked at the home for 13 years and could have retired, but she “couldn’t give it up. It’s a lovely home, I love it here”. The deputy manager said it is the best home she has worked in. On the day we visited The Birches there were enough staff on duty, and residents and staff we spoke with said that there are usually enough staff on duty. In their responses to our survey, 2 staff said sometimes they are short of staff and one staff member, when asked ‘what could the service do better?’ said “higher staff resident ratio so residents are cared for in a more detailed manner”. We looked at the documents the home has to have before new staff can start work, for three staff. The majority of the documents, including written The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 22 references, proof of identity, health declaration, criminal record bureau checks and a full employment history were in place. Staff told us that “BUPA training is good”. Training records showed that a range of training has taken place: all staff had fire safety training at least once in 2007; all staff had completed moving and handling training; and 11 staff have done first aid training. Some, but not all, staff had done infection control training, basic food hygiene and dementia training. No training had been offered to staff on how to care for people who have poor sight and/or poor hearing (sensory impairment), even though at least one of the people who live at the home has both sight and hearing loss. One relative commented that not all staff seem to understand this condition. In the AQAA the manager told us that of the 26 staff, 7 have been awarded a National Vocational Qualification (NVQ) in care, and 3 more staff are working towards the qualification. This will mean that once these 3 staff have completed the course, 38 of the care staff will be qualified. The home should have at least 50 of the staff on duty with a qualification. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 23 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, 32, 33, 35, 37, 38 People who use this service experience good quality outcomes in this area. The people who live at The Birches benefit from a home that is well managed and where their views are listened to. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager is Christine Holmes. She was registered with CSCI as the manager in May 2007. Although the manager was not on duty, it was clear that she and the senior team are competent to manage the home well and we are confident the matters we raised will be dealt with. In their response to our survey one of the The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 24 staff wrote “All in all I am very happy with my manager, she is doing a difficult job well.” The manager wrote in the AQAA that “The senior team are all commited and have the same vision as the manager in improving and maintaining the running of the home.” This was made clear to us by the deputy manager who dealt with the inspection very competently and was very helpful throughout the day. She showed us that she is enthusiastic and committed to the home and to the people who live and work there. In the AQAA the manager also told us about a number of ways in which people are asked for their views on how the home should be run. A customer satisfaction survey is carried out and residents’ meetings are held and minutes taken. One person told us that he feels able to give his opinion at any time, and sometimes the residents and “the girls” get together to discuss things. A quarterly newsletter is produced. We did not look at the records of money held on behalf of residents. In the AQAA the manager told us that the administrator deals with this, and if the person has asked their relatives to be involved, the administrator sends them a copy of all transactions from the person’s personal allowance account. We checked some of the records the home must keep. Checks on the fire alarm and emergency lighting systems are carried out as required, and everything to do with fire (for example fire doors, fire escapes, fire extinguishers and so on) is checked regularly. Staff rotas are kept up to date, and other required records, such as the reports of visits made by the provider, accidents, incidents, residents’ property, visitors to the home and so on are all maintained. A record of food provided is not kept (see Lifestyle section of this report). The manager recorded in the AQAA that checks on all equipment, such as the lift, hoists, gas appliances and so on have been done as required, and that all policies are in place and have been reviewed. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 2 X X 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 3 3 The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Evidence must be provided to show that residents or their representatives have been involved in preparing and reviewing their care plan. Evidence must be available to show that all medications are given as prescribed. When a cream is applied it must be signed for on the MAR chart. A suitable amount and range of activities and outings must be made available so that residents are kept occupied if they want to be. The previous timescale of 30/09/06 was not met. All staff must receive safeguarding training so that residents are protected from harm. Timescale for action 31/05/08 2 OP9 13(2) 04/03/08 3 OP12 16(2)(m) &(n) 31/05/08 4 OP18 13(6) 31/05/08 The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 27 5 OP26 16(2)(k) All areas of the home, including the bedrooms identified on the day of the inspection, must be kept free from offensive odours so that residents have a pleasant place to live in. 31/05/08 6 OP30 18(1)(c) All care staff must receive 31/07/08 training so that they can meet the specific needs of some of the residents, for example, sensory impairment, dementia and so on. A record of food provided must be kept in sufficient detail so that it can be determined if the diet is satisfactory for each person. 30/04/08 7 OP37 17(2) and schedule 4 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 OP21 Good Practice Recommendations The home should consider providing a shower for those people who prefer a shower to a bath. The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection 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 The Birches DS0000014883.V360477.R01.S.doc Version 5.2 Page 29 - 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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