Latest Inspection
This is the latest available inspection report for this service, carried out on 1st March 2010. it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.
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.
For extracts, read the latest CQC inspection for Birchlands.
Annual service review
Name of Service: Birchlands The quality rating for this care home is: The rating was made on: two star good service 1 8 0 2 2 0 0 9 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Sally Hall Date of this annual service review: 2 7 0 1 2 0 1 0 Annual Service Review Page 1 of 7 Information about the service
Address of service: Birchlands Barley Mow Road Englefield Green Surrey TW20 0NP 01784435153 N/A lucy.ncube@anchor.org.uk www.anchor.org.uk Anchor Trust Telephone number: Fax number: Email address: Provider web address:
Name of registered provider(s): Name of registered manager (if applicable) Ms Lucy Ncube Conditions of registration: Category(ies) : dementia old age, not falling within any other category Conditions of registration: Number of places (if applicable): Under 65 Over 65 51 0 0 51 The maximum number of service users ot be accommodated is 51 The registered person may provide the following categories of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Dementia (DE) Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service 1 8 0 2 2 0 0 9 Annual Service Review Page 2 of 7 Birchlands is a residential care home in a substantial detached property that has been purpose built to provide accommodation for fifty one service users. The home is owned by the Anchor Trust Group and is located in Englefield Green, near Egham. A selection of facilities and services including shops, church, public transport and G.P. surgeries are available locally. The home is a two storey building served by a passenger lift to both floors. A wheelchair lift provides access from the first floor to one of the seven residential units which the home is divided into. Each unit accommodates between 6 and 8 service users and has its own communal lounge and dining room with a kitchenette. Units on the ground floor have access to the garden via french doors from the lounge. All bedrooms are for single occupancy and have wash basins. Toilets and bathrooms, most with easy access baths or with a hoist facility, are provided on each of the units. The home has recently undergone a major renovation and refurbishment to improve facilities for residents and staff, and particularly for those residents with dementia. There is a large communal lounge, equipped with a television, music centre, piano and selection of books. This room is used for activities and has access to an enclosed garden area. A further area with comfortable seating and a music centre is situated centrally on the first floor. The fees at Birchlands are subject the prospective service users assessed needs and are available from the home. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection. This included, The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self assessment that focuses on how well outcomes are being met for people using the service. It also gives some numerical information about the service. Information we have about how well the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection. Relevant information received from other organisations. What other people have told us about the service. What has this told us about the service? The last inspection took place on 18th February 2009 the report was positive with no requirement being made following the site visit. The home completed and returned their annual quality assessment. The document was comprehensive and informative. It identified areas where the service had improved in the last year and others where further developments were being planned. It included evidence that the service regularly sought the views of service users and other stakeholders to inform their planning. Throughout the annual quality assurance assessment it was evident that equality and diversity issues were promoted and incorporated within the service. There have been 38 complaints made to the home since the last inspection and all but two of these were dealt with with in the time scales detailed within the camplaint procedure. Just three of the compaints were upheld. Although this may seem a high number it is also good as it is apparent that people feel comfortable to in making their views known. The home has strategies in place to ensure that those who they provide a service to can make their views and complaints known. The surveys recieved back by the commission also evendenced that people felt confident their views will be listened to, taken seriously and acted upon. The home has made two reffereals to safeguarding during this time, and is proactive in informing the commission of incidents that happen in the home. Staff training all staff have undertaken an induction which meets the Skills for Care standards. The numbers of care staff who have been awarded an NVQ, National Vocational Qualifications level two or above is above 50 with 20 of the 37 staff Annual Service Review Page 4 of 7 currently with the award. The home does have other staff who are working towards the NVQ award. The AQAA also confirmed that mandatory training is undertaken which includes dementia awareness. All relevant employment checks are carried out to ensure staff are appropriately employed and service users remain in safe hands. All staff receive training which includes the manditoring training and more specialised training such as dementia. The AQAA identified other areas of improvements mainly focused around informing and involving service users. The AQAA confirms the home understands sevice users with specific needs relating to cultural, social, race, gender, identity, disability, sexual orientation, age, religion and belief. Extremely important when caring for people with dementia. The home when admitting new service users ensure through the person centred individual Care plans that as much information is gathered in order to meet each persons diverse needs. The home has arranged equality and diversity training for its entire staff. Quality assurance is taken seriously by the home and the AQAA describes different ways in which the care with in the home is monitored. As well as visits to the home by senior management, surveys are used, regular meetings are held with service users, their families and staff. Feed back from these meetings etc. are used to improve the service that the home offers. It was noted in the AQAA that the policies and procedures in the home have not been reviewed annually. This is a good practice requirement, all policies must be seen to have been reviewed at least annually in order to ensure they meet current legislation and guidance. We sent out surveys prior to this inspection, those received from service users were generally positive and we received comments such as , the meals are good, there are a lot of activities available, they take me to the clinic and nurses visit me at the home. All said that the home is always kept clean, and that staff were available when they were needed. A member of staff replied they felt the home offers a safe environment for everyone, that the activities and meals are good and staff work together as a team. Other comments made were regarding employment issues and not part of our regulatory field. A survey received from a GP who works closely with the home, stated that over the past 4 years the facets of the service have improved dramatically. Good knowledge of the patients by care staff when we visit, caring attitude, good organisation. They also felt that the staff and manager usually had the skills and experience to support people in the home, and that staff always respect service users privacy and dignity. What are we going to do as a result of this annual service review? Annual Service Review Page 5 of 7 There will be no change to the inspection plan and we will do a key unannounced inspection by 18th February 2011. However, we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 6 of 7 Reader Information
Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline:
Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a copy of the findings in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Annual Service Review Page 7 of 7 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
