Care Home: Birchville Court Nursing Home

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What the care home does well People living in the care home were complimentary of the staff, food and their rooms. Records were generally maintained in good order. Staff commented that they received appropriate support from management and were happy to be working at the care home. The management operated an open door policy and is transparent. The Inspector had the opportunity to speak to a variety of people throughout the day, including several residents as well as some visitors. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 There was a range of positive comments made. The core staff team have been working within the home for several years and therefore provide a stable and consistent team of people that the residents can feel confident in providing their care. The environment has been redecorated within the past twelve months and the majority of the areas within the home are bright and pleasant. What has improved since the last inspection? The manager and proprietor continue to further improve and develop the environment which now presents as a very comfortable and homely place in which to live. The manager continues to works hard to support the care staff on duty and often works on shift to provide additional support and guidance, where necessary. What the care home could do better: The manager must improve the regularity of both supervisions and training. There was no indication that staff receive any formal supervisions and no schedule or documentation held. The systems to audit and monitor the quality of the service provided need to be improved as we found minimal evidence that standards within the home are monitored on a regular basis, using a formal process. The standard of cleanliness with the service must also be improved to ensure all areas of the home are maintained to an acceptable standard. The range of activities provided is limited. Activities are currently provided by care staff, in addition to their existing duties. This limits the opportunities for people to enjoy and to be offered “meaningful and lifestyle experiences within the home that matches their expectations and preferences that satisfies their social, religious, cultural and recreational interest and needs”. The manager must improve this service in order to meet standards relating to providing meaningful activities to people that reflect their personal preferences and satisfy their religious, cultural and recreational interests. Care plans must be improved to contain all the required information and must be signed by either the person using the service or their representative. There must evidence provided to ensure that all staff have been provided with the necessary training in order to carry out their role effectively. There must be adequate information held on each member of staff’s personal file to confirm all the required checks have been carried out in order to protect the people using this service.Birchville Court Nursing HomeDS0000019293.V375701.R01.S.docVersion 5.2Staff meetings must be held on a regular basis in order to ensure staff receive the support and guidance from the manager in carrying out their role effectively and safely. There should be an up to date Statement of Purpose and Service User Guide maintained within the home in order for people using the service and prospective service users to have the information necessary to make an informed choice about where they would like to live and the services that are provided. The dignity of people should be respected and maintained at all times. There were two practices observed during this inspection that were cause for concern. See the health and personal care section and requirements section of this report for details of these findings. The current induction programme is limited and requires updating as the current document is limited in the information that is provided and does not relate or provide a link to either the minimum standards or the Skills for Care induction standards. There should also be evidence provided within this induction programme of the training provided as part of the persons induction programme. Key inspection report CARE HOMES FOR OLDER PEOPLE Birchville Court Nursing Home Heathbourne Road Bushey Heath Hertfordshire WD23 1PB Lead Inspector Julia Bradshaw Key Unannounced Inspection 19th May 2009 10:00 DS0000019293.V375701.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) 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. www.cqc.org.uk Internet address Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchville Court Nursing Home Address Heathbourne Road Bushey Heath Hertfordshire WD23 1PB 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) 0208 421 9110 0208 421 9117 birchvillecourtcarehome@tesco.net Peach Glen Limited Mrs Christine Kelly Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home may accommodate 39 older people who require nursing care. 25th May 2007 Date of last inspection Brief Description of the Service: Birchville Court is situated on the outskirts of Bushey Heath. The two storey period building with a modern ground floor extension to the rear is set back from the road in extensive grounds. Visitors parking is provided to the side of the main building. The home has been extensively modernised in the last eighteen months providing accommodation in 39 single rooms many of which have en-suite toilets and wash hand basins. A feature of the home is the overhead-tracking hoists, which have been provided in the bathrooms, shower room and toilets. There is a large lounge, sunroom, conservatory and dining room on the ground floor. The rooms in the older part of the house and the entrance hall are decorated in period style. Information regarding the service is available in the Statement of Purpose and the Service User Guide. These and a copy of the last inspection report are freely available on request. The range of fees for Birchville Court are between £609 - £750. Birchville Court Nursing Home DS0000019293.V375701.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 that the people who use this service experience adequate quality outcomes. The focus of the inspections undertaken by the Care Quality Commission is upon outcomes for the people who use the service and their views of the service provided. The primary method of inspection used was case tracking which involved selecting two people and tracking the care they received through looking at their care records, discussion where possible with the people who use the service, the care staff and observation of care practices. The last Key inspection was carried out on the 25th May 2007 and an annual service review was completed on the 13/05/08. This visit was unannounced and planning for the visit included assessment of the notifications of significant events, which had been received from the service to the Care Quality Commission. We looked at the last Inspection Report and information on safeguarding and complaints since the last inspection. We also looked at the last Annual Quality Assurance Assessment (AQAA) and reviewed what the service has improved in the last twelve months and its plans for the next twelve months. The AQAA is a self assessment document required by law in which the provider tells us how well they think they are meeting outcomes for individuals. During the visit information was gathered directly from the staff, people who use the service and relatives and or visitors to the service. The visit took place over one day and by one Inspector. This enabled the inspector to directly and indirectly observe the care practices and the day to day operations of the service. A selected tour of the building was conducted during which the inspector spoke with people who use the service, staff and visitors and the registered manager. What the service does well: People living in the care home were complimentary of the staff, food and their rooms. Records were generally maintained in good order. Staff commented that they received appropriate support from management and were happy to be working at the care home. The management operated an open door policy and is transparent. The Inspector had the opportunity to speak to a variety of people throughout the day, including several residents as well as some visitors. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 6 There was a range of positive comments made. The core staff team have been working within the home for several years and therefore provide a stable and consistent team of people that the residents can feel confident in providing their care. The environment has been redecorated within the past twelve months and the majority of the areas within the home are bright and pleasant. What has improved since the last inspection? What they could do better: The manager must improve the regularity of both supervisions and training. There was no indication that staff receive any formal supervisions and no schedule or documentation held. The systems to audit and monitor the quality of the service provided need to be improved as we found minimal evidence that standards within the home are monitored on a regular basis, using a formal process. The standard of cleanliness with the service must also be improved to ensure all areas of the home are maintained to an acceptable standard. The range of activities provided is limited. Activities are currently provided by care staff, in addition to their existing duties. This limits the opportunities for people to enjoy and to be offered “meaningful and lifestyle experiences within the home that matches their expectations and preferences that satisfies their social, religious, cultural and recreational interest and needs”. The manager must improve this service in order to meet standards relating to providing meaningful activities to people that reflect their personal preferences and satisfy their religious, cultural and recreational interests. Care plans must be improved to contain all the required information and must be signed by either the person using the service or their representative. There must evidence provided to ensure that all staff have been provided with the necessary training in order to carry out their role effectively. There must be adequate information held on each member of staff’s personal file to confirm all the required checks have been carried out in order to protect the people using this service. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 7 Staff meetings must be held on a regular basis in order to ensure staff receive the support and guidance from the manager in carrying out their role effectively and safely. There should be an up to date Statement of Purpose and Service User Guide maintained within the home in order for people using the service and prospective service users to have the information necessary to make an informed choice about where they would like to live and the services that are provided. The dignity of people should be respected and maintained at all times. There were two practices observed during this inspection that were cause for concern. See the health and personal care section and requirements section of this report for details of these findings. The current induction programme is limited and requires updating as the current document is limited in the information that is provided and does not relate or provide a link to either the minimum standards or the Skills for Care induction standards. There should also be evidence provided within this induction programme of the training provided as part of the persons induction programme. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Birchville Court Nursing Home DS0000019293.V375701.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 Birchville Court Nursing Home DS0000019293.V375701.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 -6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Adequate information is available to people looking to live at the care home so that they can make a decision about the home. Each person at the care home has an assessment of his or her needs carried out prior to moving to the home, in order to ensure the service has the capacity to meet their needs. EVIDENCE: Admissions are not made to the service until full needs assessment has been undertaken. A senior person always completes the assessment prior to admission to the service. A number of pre assessments were seen and completed to an acceptable standard. The service has the capacity to support people who use the service and respond to diverse needs that may have been identified during the assessment process. The service should maintain an up to date Statement of Purpose and Service User Guide within the home at all times. This should be made available Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 10 for both people using the service and also for prospective users of the service. On the day of this inspection neither of these documents had been updated to include the changes in services from 2007 to the current year. Birchville Court Nursing Home DS0000019293.V375701.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 10 and 11. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can not be assured that care plans reflect the developing and on going needs of the individual to ensure all personal and healthcare needs are provided for and met effectively, safely and with dignity. EVIDENCE: Three care plans were inspected. The service needs to ensure they are providing the appropriate care and support meeting the health and welfare needs of the individual. Standard 7 and 8 can only be fully met if there is a comprehensive care plan in place. The three care plans inspected did not contain” end of life pathway” sections in them and none of the care plans had Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 12 been signed by the person using the service or their representative. This must be evidenced in order to ensure the service user has been involved and consulted on the drawing up and implementation of their care plan. Two of the care plans inspected did not have up to date individual risk assessments in place. One falls risk assessment was last reviewed on the 12/07/07. One nutritional assessment was last reviewed on the 20/10/05. Risk assessments for people who were at risk of choking were seen on two care plans. The initial assessment created by the manager is detailed and covers every aspect of the persons needs. People spoken to on the day of the inspection and comments received by way of surveys carried out by Birchville Court were generally positive about the way that care is received in terms of preserving rights and dignity. However during this inspection we observed staff assisting people with their lunchtime meal without any interaction taking place by one particular member of staff. Also one service user was placed facing a blank wall in the connecting dining room for the entire inspection process. This was raised at the feedback session with both the manager and the proprietor as being inappropriate, undignified and punitive. The manager agreed to cease this practice immediately and place this person back into the sitting room with everyone else. Positive comments were also received on the day including “The staff are all lovely, always happy to help you “nothing is too much trouble”. The service uses four main G.P. surgeries within the local area and the service arranges home visits for both the chiropodist and the optician. Medication records were spot-checked and found to be accurate. The medication is held within a large locked room on the ground floor. The service has a rigorous medication procedure in place. The manager/proprietors wife has responsibility for ordering and the disposal of medication. The home has a contract with a local pharmacy for supplying the monthly medication. There were no regularities found with medication procedures during this inspection. The service also currently holds and administers controlled medication. The administration of these controlled medications was checked and all records reconciled. The manager is knowledgeable in the administration of medication and ensures that all practices are carried out safely and accurately. Although the medication procedures are monitored and checked regularly this is an informal process and not recorded as part of a Quality Assurance system. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12 -15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service cannot be sure that Birchville Court will provide activities and opportunities that match their expectations, as they are only enabled to exercise some control and involvement over their lives. People who use the service can be assured that they will have healthy, wellpresented meals and snacks. EVIDENCE: A formal advertised activity programme was not available on this visit. There is no designated activities coordinator within this service. Activities are arranged on a day to day basis and include a monthly visit from an outside entertainer and bingo sessions are held on a Thursday. The hairdresser visits every Tuesday. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 14 The AQAA states that “Activities are organised to suit the needs and abilities of the service users and suggestions for types of stimulation are welcomed”. However on the day of this inspection we were unable to observe any activities taking place. We were able to observe the lunchtime meal being served and the meal of the day was mince beef, vegetables and creamed potato. There are several people who require soft diets and two peg feeds. The cook stated that “There is an alternative meal provided if people do not like the main meal offered”. The meal was sampled by the inspector and found to be flavoursome and plentiful. Several people require assistance with eating and this is carried out within the two main areas of the home. We observed four people being assisted with their meal and one member of staff did not interact once with the person they were helping and the whole process appeared rushed. Mealtimes for everyone should be provided in a relaxed environment and an occasion that should be enjoyed creating an opportunity for people to have some one to one time with individual staff members. The AQAA states that “Service users are given as much time as they need to consume their meals, and never hurried”. The findings of this inspection do not confirm this statement. One care plan checked had an out of date nutritional assessment in place dated 20/10/05. The expectation is that this assessment would be reviewed at least once a year to ensure that people’s nutritional needs are being met. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users can be confident that there is a complaints procedure in place for them to access to raise any concerns. EVIDENCE: The service has a complaints procedure in place. A record is maintained of any complaints made detailing actions and outcomes as necessary. People using the service have been informed about the complaints procedure. The AQQA stated that there have been no complaints received since the last inspection was carried out. Records to confirm this were seen on the day of the inspection. Four out of the five surveys/questionnaires we received indicated that people were aware of how to make a formal complaint. A detailed procedure is in place to ensure that people using the service are protected from abuse and harm. However, some of the practice observed during this inspection shows an inconsistent approach to respecting people’s dignity and individuality. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 16 Generally staff employed within the home are all subject to enhanced Criminal Records Bureau disclosure. However on the day of this inspection one staff file inspected only had one written reference and one telephone reference, without an address or signature confirming who the reference was from. This was feedback to the management at the end of the inspection for their attention. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have been provided with a comfortable and welladapted environment that is suitable to meet their needs. EVIDENCE: The home and its surroundings offered a pleasant, comfortable and safe environment to people living in the care home. These were kept clean and generally well maintained. Bedrooms were personalised offering a homely, lived in feel. People spoken to said that they were happy with their bedrooms and other facilities. “I like my room, its feels almost like home”. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 18 The home has adequate numbers of domestic staff. There were a couple of issues relating to one bedroom that had a dirty counterpane on it and a dirty floor but this was an isolated finding. The home provides ample communal space including a bright and airy conservatory. The inspector would like to thank the resident who took the time to show them around. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27- 30. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can not be assured that staff are appropriately trained or supervised to meet their needs. EVIDENCE: The rotas were checked and confirmed that the service provides adequate staffing numbers throughout both the day and night time. There was inadequate evidence, within the staff training records held to confirm that all staff have received the mandatory training necessary to carry out their role effectively. However the AQAA states that “At present there are 30 care staff and 93 are NVQ 2 qualified or working towards it”. However, the AQQA completed by the manager does not make any reference to the practice or implementation of staff supervisions. During the feedback session at the end of this inspection the manager stated that she was “unaware of the requirement that staff should receive a minimum of six supervisions per year”. We confirmed this required standard by identifying it, with the manager, from the relevant pages of the Care Homes Regulations and National Minimum Standards for older people documentation that was held within the manager’s Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 20 office. The manager was unable to provide evidence that all staff have received the appropriate and necessary mandatory training to carry out their effectively. The manager was able to evidence that new staff are provided with an induction programme, although this is limited in the information provided and is not linked to the “Skills for Care” induction standards. Two staff files were checked as part of this inspection. One file only contained one reference. The standard requires that two written references must be obtained prior to a new member of staff commencing employment. This was discussed at the end of the inspection as part of the feedback session to both the manager and the proprietor. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can not be assured that the home is run in their best interests and that policies, procedures and systems in place are implemented to ensure their continued well being and safety. EVIDENCE: The manager works hard to provide a relaxed and homely approach to managing this service. However some systems in place do not currently meet the needs or protect the people living within Birchville Court. The main issues highlighted relate to staff having limited interaction with people, care plans Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 22 that are incomplete and have not been signed by the person using the service or their representative. The current activities provided do not reflect the interest and social interest that are identified within the initial assessment or within the individual care plan. The manager is advised that they need to find ways to ensure that the expectations and desires of the people who use the service regarding social and leisure activities, and ways to ensure people retain independence is sought and choice is promoted at all times. All fire records and health and safety checks were up to date on the day of the inspection. Appropriate safeguards are in place to ensure peoples money and personal valuables are kept safe. The environment is generally well maintained, providing comfortable and homely communal spaces in which people can relax and receive visitors. Infection control standards are being maintained including adequate hand washing facilities throughout the home. The laundry room was seen and provides adequate facilities to ensure people’s washing is managed effectively. There were two issues relating to one person’s bedroom that were identified during this inspection and these were addressed immediately by the manager and proprietor. There is a limited formal Quality Assurance system in place as the proprietor and manager have daily contact and therefore often any issues relating to the running of the service are managed on an informal basis. However these informal checks should be evidenced by using a more formal recording system where the quality of the service can be measured as part of the general overview of the Quality Assurance process. This should also include regular consultation and involvement, where appropriate, from people using the service. We were able to see that the registered manager is both fully committed to providing a caring approach to the people living at Birchville Court and clearly works tirelessly to achieve this. However there are specific standards and regulations that are required to be met as part of this inspection process and as part of being the registered manager. These primarily relate to the recruitment, supervision and training of staff. The maintenance and reviewing of care plans and the dignity and respect of the people using this service. These issues have been identified throughout this report and as part of the recordings of this inspection. All issues identified within this report and required in order to protect the people using this service. Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 23 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 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 x x 2 2 2 Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 Timescale for action 30/09/09 2. OP12 OP13 OP33 16 (2) (m) & (n) 3. OP14 OP10 OP30 OP33 12 (4) 4. OP30 18 1 (C) i Care plans must provide a full and detailed reflection of the person’s holistic needs and been more person cantered, with clear evidence of the person using the service’s involvement. Evidence must be provided to 30/09/09 confirm that people living at Birchville Court are consulted and offered a range of meaningful activities and opportunities for social outings. The manager must ensure that 31/07/09 people’s rights and dignity are respected at all times and any practices that compromise these rights must be addressed immediately and managed effectively in order to protect the people living at Birchville Court. The staff training programme 30/09/09 must incorporate specialist training, where appropriate, to ensure that all staff are equipped with the necessary skills and underpinning knowledge to carry out their roles effectively. All the required documentation DS0000019293.V375701.R01.S.doc 5. OP29 19 (1) 31/07/09 Page 25 Birchville Court Nursing Home Version 5.2 Schedule 2. relating to staff recruitment must be in place prior to the person commencing employment, in order to safeguard and protect the people who use this service. 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 OP12 Good Practice Recommendations The activity programme should be created from the initial individual assessment and care plans, monitored and reviewed regularly to ensure people are offered a choice of meaningful activities, where appropriate. A consistent record of evidence of the activities provided should be maintained. All staff should engage and communicate with people using the service at all times. 2. OP10 Birchville Court Nursing Home DS0000019293.V375701.R01.S.doc Version 5.2 Page 26 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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