Inspection on 27/06/06 for Braceborough Hall

This inspection was carried out on 27th June 2006.

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 26/10/05

Braceborough Hall 14/06/05

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 Key Unannounced Inspection 27th June 2006 09:00 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 Braceborough Hall DS0000002331.V301325.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. Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Braceborough Hall Address Braceborough Lincolnshire PE9 4NT 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) 01778 560649 Mrs Susan Linda Burcham Mrs Susan Linda Burcham Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2005 Brief Description of the Service: Braceborough Hall is a large detached stone building, the villages former main house. There is a modern ground floor extension and a conservatory attached to the main building, but the home 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, 17 people were being accommodated. The home provides longterm residential care, with four bedrooms kept for respite care and there is also a provision for day care for one person on one day of the week. 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. Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took into account any previous information held by CSCI including the homes previous inspection reports, their service history, the homes pre-inspection questionnaire and residents questionnaires sent to the home by the Commission prior to this inspection. The site inspection consisted of case tracking a sample of two residents’ records and assessing their care. Some policies and procedures were examined and some records concerning the safety of the home were also seen. Three residents, three care and ancillary staff and two visitors were spoken with. The proprietor was present throughout the inspection. What the service does well: What has improved since the last inspection? Recent improvements to the home have included the upgrading of two showers and two bathrooms to include new tiling and the complete refurbishment of Room 6. Other rooms seen were comfortably furnished. One resident said ‘my room is at the top and it has a lovely outlook’. The Deputy Manager has been working hard to update all policies and procedures and has developed a very comprehensive risk assessment procedure. Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 6 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 DS0000002331.V301325.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 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 the following standard(s): 3, 6 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to the service. 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. The home does not provide intermediate care. 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 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 four dedicated respite rooms. One visitor said ‘I looked at 8 homes in all and this Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 9 one was outstanding, particularly in terms of the staff, who had the best attitude to residents’. Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The home’s records give a clear and comprehensive picture of the health care needs of the residents and enable staff to meet these needs with sensitivity and regard for their privacy and dignity. EVIDENCE: Two residents were selected for case tracking; the revised care plans were 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. The Deputy Manager 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 home does not receive a regular visit from a pharmacist. The privacy and dignity of residents was observed throughout the inspection, with staff members treating residents with courtesy and friendliness and knocking on rooms before entering. Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 12-15 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to the service. 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. Recent activities included trips to local garden centres, a slide show, quizzes and a ‘Mexican’ night with Mexican food and dancers. One resident said how much she had enjoyed the recent visit from a group of clarinettists, who played in the hall. Future events included a visit and talk from the Cromer Lifeboat men, who were the recipients of last year’s charity, chosen by the residents, and the annual garden fete to be held in August. The local community also participates in these events. Residents’ meetings were held and there was a ballot on what future activities they wished to take part in. 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. One resident said ‘If we like we can choose a whole week’s menus, then if we Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 12 don’t like the food we can all discuss it with the resident that’s chosen them!!’ The cook went to all residents in the morning and informed them of the day’s main meal. Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. 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. Information about an advocacy service was displayed in the hall and the home had an advocacy policy. Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to the service. The residents live in a comfortable, pleasant and safe environment, with both private and communal space being generally suitable for their needs. The grounds in particular offer a well tended, attractive and quiet place to sit in. EVIDENCE: General observations made during the visit showed that the home was maintained to a good standard internally. Two showers and two bathrooms had recently been refurbished. The proprietor 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 particularly well-tended and offered seclusion and privacy from the public. The home was tidy, clean and free from odours; one resident who was sitting in the conservatory said ‘The gardens are beautiful – look at the view from here – it’s lovely!’ Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. 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 ‘ smashing’ and another said ‘they’re very patient and kind’. The most recent staff member to be interviewed said she had given two references, which were followed up, had a CRB check and had undertaken a three-day induction programme before commencing work. Staff records seen verified this. The proprietor, who is a qualified nurse, still worked actively in the home. The core staff group is stable, although there are currently two vacancies for night care staff. The proprietor 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. Regular tests were also devised for both new and existing staff members. Training records showed that 6 care staff had achieved the National Vocational Qualification at Level 2, with a further 2 members working towards it and 3 staff were working towards NVQ at Level 3. The training plan showed that recent training included moving and handling and first aid updates. On the day of the inspection there was a total of 8 staff members including three carers for 17 residents; this was in excess of the recommended staffing forum. Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. The home is managed competently and the staff are supported and supervised in carrying out their respective roles. EVIDENCE: The proprietor has now delegated responsibility for policies, procedures and certain records to the Deputy Manager, who has worked hard to update these. In particular, she has devised a very comprehensive risk assessment procedure both for rooms used by residents and for the residents when in those rooms. The proprietor 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 proprietor was approachable and accessible on a daily Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 17 basis; residents and visitors said that if they had any concerns she 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 self-assessment form and a questionnaire on caring practices; quarterly staff 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 DS0000002331.V301325.R01.S.doc Version 5.2 Page 18 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 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 19 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. 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 OP9 Good Practice Recommendations It is a recommendation that as a matter of good practice a pharmacist is contacted to advise on the storage of medications. Braceborough Hall DS0000002331.V301325.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby 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 DS0000002331.V301325.R01.S.doc Version 5.2 Page 21 - 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. 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