Inspection on 14/06/05 for Braceborough Hall

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Braceborough Hall 27/06/06

Braceborough Hall 26/10/05

Braceborough Hall 19/01/05

Braceborough Hall 27/07/04

Braceborough Hall 19/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Braceborough Hall Braceborough Lincolnshire PE9 4NT Lead Inspector Julie Western Unannounced 14 June 2005 09.30 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. Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Braceborough Hall Address Braceborough Lincolnshire PE9 4NT 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) 01778 560649 Mrs Susan Linda Burcham Mrs Susan Linda Burcham Care Home 25 Category(ies) of Old Age (OP) - 25 registration, with number of places Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19/1/05 Brief Description of the Service: Braceborough Hall is a large detached stone building, the villages former Hall. There is a modern ground floor extension and a conservatory attached to the main building. Although converted to a Care Home, it has retained many of the original features in the older part of the building. There are large well maintained landscaped gardens, with walks and seating for residents and a drive and car parking to the front of the home.The home is situated in the centre of Braceborough village, with the towns of Stamford and Bourne and the large village of Market Deeping all nearby, with a good range of facilities. Personal care services are provided for up to 25 older people and on the day of the inspection, 21 people were being accommodated. The home provides longterm residential care, with three bedrooms kept for respite care and there is also a provision for day care for one person on one day of the week;this did not form part of the inspection. The basic philosophy of the home is to promote a warm family atmosphere, free from any forms of institutionalisation. Residents are encouraged to maintain their chosen lifestyles and maintain their independence. There is a residents’ charter, which reflects the basic values of choice, empowerment, rights of citizenship and advocacy. The home is owned and managed by an individual proprietor, who was present throughout the inspection. Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 4 hours. A tour of the building took place and care records were inspected. The main method of inspection used was called ‘case-tracking’; this involved selecting three residents and tracking the care they received through the checking of their records, discussions with residents, visitors and care staff and observation of practices. Some policies and procedures were examined and records concerning the safety of the home were also seen. 6 of the 21 residents, 4 of the 24 care and ancillary staff and six visitors were spoken with. The Manager was present throughout the inspection. N.B. Feedback comments were not included in this inspection report. What the service does well: This home has set a high standard of care; it has achieved a prominent position and a good reputation in the local community. It does this by maintaining good care practices and good relationships with the service users and their families. The residents were generally very positive about the care they received from the staff. A visitor said ‘my mother came for respite care and stayed – she has been to another home but didn’t settle there’. The resident said ‘I wouldn’t like to go home now, I love it here’. The home is adequately staffed with employees who are experienced and competent to care for older adults. Training is to a good standard, with ongoing training. The home is very much led by the owner who is also the Manager, who she keeps a close watch on the standard of care in the home. The staff group is stable, most of the care staff having been at the home for many years; this provides a consistency of care practice. Quality assurance is well managed, with the responses gathered from questionnaires to the residents being used to create a bar graph showing the areas needing improvement. These were then discussed and acted upon. Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 7 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 Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 8 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) 1-6 The home clearly sets out what it intends to provide for residents and this information is freely available to residents and their visitors. Prospective residents are encouraged to visit the home before making the decision to move in on a permanent basis. EVIDENCE: The statement of purpose and service user guide were comprehensive, easy to read and in a large clear print, making it easy for older people or those with poor eyesight to read. A copy of the most recent inspection report was on the notice board in the entrance hall. The policies and procedures manual needs to show that it is updated regularly. The Manager said that she or the Deputy Manager in her absence were involved in the pre-assessment of prospective residents, either visiting them in a hospital or care setting or their own homes. Short trials or weekend visits could be made prior to residents making a final decision to move into the home on a long-term basis. The home has three dedicated respite rooms. One resident said ‘we just liked the feeling of this home; after having looked at twelve other homes this was the best’. Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 9 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) 7,8,10,11 The home’s records, although concise, give a clear picture of the needs of the residents and enable staff to meet their needs with sensitivity and regard for their privacy and dignity. EVIDENCE: Three residents were selected for the ‘case tracking’; their care plans were concise but clear as to what was required to meet each resident’s needs. Other information regarding residents was kept in a separate folder. Risk assessments for moving and handling were recorded for each resident and displayed on a notice board in the care station. One staff member was responsible for ensuring that care plans were updated regularly. The home had full procedures for the management of medication and training records showed that all staff involved in distribution of medication had received training. The privacy and dignity of residents was observed throughout the inspection, with staff members treating residents with courtesy and friendliness and knocking on room doors before entering. A resident said ‘the staff are marvellous – very good’. Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 10 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) 12,13,15 Social activities are extensive and create a variety of events and activities which residents are informed about. The residents exercise choice about which activities, if any, they wish to participate in and what meals they want to eat. EVIDENCE: Service users and visitors spoken with said there was a variety of events and activities for residents to take part in if they wished, although two residents said they would rather stay in their rooms and receive regular visits from their families. Recent activities included games of petanque on the lawn in good weather, visits to the theatre, a slide show, a wine and cheese evening and a Tombola for charity. The next event to be held was the annual garden fete, which was attended by the village community. The Manager runs a weekly painting class for all residents who wish to take part. Six visitors were spoken with; one was staying at the home as she had travelled from abroad to be with her relative following the death of her husband. Menus had choice and variety and were balanced, with a use of fresh fruit and vegetables. The mid-day meal was observed being eaten and residents spoken with said they enjoyed the food, although one said she thought the quality had deteriorated since the arrival of the new cook. The Manager was aware of these comments and had discussed the issue with the resident and her relative. Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 11 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 complaints procedure is clear and gives residents and their relatives the confidence that comments and concerns will be listened to; there is a robust adult protection procedure. EVIDENCE: Residents and visitors to the home all said they did not wish to make a complaint but knew how to make a complaint. The home had received one complaint in the last 12 months; this had been responded to appropriately and within the given time. There was a clear adult protection procedure, which was linked to the Local Authority procedures. Staff members spoken had received training on adult abuse and were knowledgeable about complaints. Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 12 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) 19,20,21,22,2426 The residents live in a comfortable, pleasant and safe environment, with both private and communal space being generally suitable for their needs. EVIDENCE: A tour of the premises showed that the home was maintained to a good standard internally. The Manager explained that staff members cleaned and maintained all wheelchairs regularly, as she felt it important for the staff to be aware of health and safety issues. The grounds and gardens were well-tended and offered seclusion and privacy from the public. Some ceilings showed damage from a previous storm damage to the roof; the Manager was aware of this and there was an ongoing programme to repair these. The home was tidy, clean and free from odours; one resident commented that her room was dusty but acknowledged that there was a lot of ‘clutter’ in her room. The Manager explained that the cleaner had recently been sick and dusting had given way to essential cleaning. Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 13 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) 27,28,30 Staff numbers are in sufficient quantity for them to be able to care for the residents. Staff members are suitably trained, qualified and competent; they undergo an induction programme before commencing their duties. EVIDENCE: The residents were positive about the care they received; one said ‘ the staff are all good’. Anther said she had no complaints at all about the staff. The most recent staff member to be interviewed said she had given two references, which were followed up, a CRB check and undertaken a three day induction programme before commencing work. Staff records seen verified this. The Manager, who is a qualified nurse, still worked actively in the home. The staff group is stable and there was only one vacancy for a part time and relief cover night carer. The Manager explained that night carers were given a trial night’s duty before being considered for the job and residents were asked about the suitability of potential staff. Training records showed that 9 care staff had achieved the National Vocational Qualification at Level 2, with a member working towards it and 3 staff were working towards NVQ at Level 3. The training plan showed that all statutory training was being undertaken, with the most recent training being on infection control, safe handling of medicines, fire training and core skills with TOPSS. Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 14 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) 31,32,33,36,37,38 The home is managed competently and the staff are supported and supervised in carrying out their respective roles. EVIDENCE: The owner of the home is also the Manager and is a Registered General Nurse; she has owned and managed the home for 20 years. She has the D32 and D33 Assessor’s award. Observations showed that the home had an ‘open door’ policy and the Manager was approachable and accessible on a daily basis. The Manager operated a quality control system whereby residents were requested to complete a questionnaire, data from which was then used to create a bar graph showing the responses. These were then analysed and discussed at staff meetings. Residents and visitors said that if they had any concerns the owner was always ready to listen and act upon them. Staff records showed that supervision took place and joint appraisals were held using a Managerial Development Skills Matrix. Staff members were also asked to complete a selfassessment form and a questionnaire on caring practices; quarterly staff Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 15 assessments were used. The home had its own Codes of Conduct for staff and also used the General Social Care Council’s Codes of Conduct. Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 16 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 4 3 3 Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 17 none 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations It is a recommendation that the policies and procedures manual can demonstrate that it is being reguarly updated. Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Unity House, The Point Weaver Road Lincoln LN6 3QN 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 Braceborough Hall C53 C04 S2331 BraceboroughHall V232728 140605 Stage 4.doc Version 1.30 Page 19 - 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!