Inspection on 02/11/05 for Bracken House

This inspection was carried out on 2nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Bracken House 12/09/07

Bracken House 19/09/06

Bracken House 25/05/05

Bracken House 14/12/04

Bracken House 09/06/04

Bracken House 21/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Bracken House Bracken Close Burntwood Nr Walsall WS7 9BD Lead Inspector Mrs Wendy Grainger Unannounced Inspection 2nd November 2005 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 Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 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. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bracken House Address Bracken Close Burntwood Nr Walsall WS7 9BD 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) 01543 686850 jakki.hamer@staffordshire.gov.uk Staffordshire County Council, Social Care and Health Directorate Jacayln Ann Hamer Care Home 36 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (36), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (20), Old age, not falling within any other category (20) Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 3 Dementia (DE) - Minimum age 50 years on admission Date of last inspection 25th May 2005 Brief Description of the Service: Bracken House was built in 1968 to provide care and accommodation to older people. Located on an estate the home is not in a conspicuous position, overlooking a school and near to the centre of the village of Burntwood. The City of Lichfield is approximately four miles away. Standing in its own grounds the home continues to be upgraded internally and externally. Occupancy at Bracken House is for thirty-six older people. The home provides care for long term stay older people with dementia or related conditions of old age. The two-storey building has bathing and toilet facilities throughout the home. The first floor can be accessed via the stairs or shaft lift. There are no en-suite facilities. Within the home there are three lounges, with a large separate dining room off one of the lounges. Roseview is a selfcontained dining room/lounge with a small kitchen area. The laundry and main kitchen are located on the ground floor away from any service users bedrooms. The home has a separate hairdressing room, treatment room and staff room on the ground floor. There are plans to reconstruct the home to include three separate group living dining room areas. The number of bedrooms within the home will reduce by one. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on the 2nd November 2005. The Head of Home, Head of Hotel Services, residents and the staff assisted the inspector. Documents, records and reports were made available to the inspector. At the time of this inspection the home was undergoing major work to create three separate lounge/diners for residents with differing needs and dependency levels within the home. Four of the residents had chosen to go to another home in the area while the work to their part of the home was being reconstructed. Other residents had moved by choice into an alternative area internally. Residents were finishing breakfast when the inspector arrived; one of the residents alerted the management to the visit, which continued in the same relaxed manner. During the visit the Service Development Manager visited to see the Head of Home. Staff went out to a funeral for one of the residents, to pay their respects. The activity person was having a quiz in the Rose lounge, residents responded well and appeared to be enjoying the session. Assessments for prospective residents were on hold at this time due to the building work. Each of the resident’s needs physical and health were being met via the plan of care written and evaluated monthly. The staff were competent and trained to offer the appropriate care to the residents. Residents responded in a positive manner when assisted by any of the staff. The management of the home was part of the team providing care and support. The atmosphere was relaxed despite the building work; the company responsible had eliminated disruption to a minimum. Arrangements were in place for the continued health care from other professional agencies. During the visit one of the District Nurses visited, in her opinion all the staff were “professional, polite and helpful” advice was always followed and the home were aware that the District Nursing service was available. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 6 The medication system remained unchanged, stored in a satisfactory manner. One person chooses to self-administer his medication; all precautions were taken and a risk assessment had been completed. The home had a full activity programme available to any individual. The staff in their own time raised funds for the resident’s comfort funds, the most recent event was a bike ride. A Christmas event away from the home is planned for late November this will incorporate a large raffle to further increase the funds. Details of entertainment were displayed on the notice board. Menus were displayed daily on the notice board, meals were prepared by qualified cooks. The menus were well balanced and of a nutritious content, residents were consulted about the food served during the residents meetings. Daily choices were made for each meal. Despite the building work at one end of the home the home remained extremely well maintained, from the sample seen there were no malodours identified. Each resident had access to the communal toilet and bathing facilities throughout the home. On the completion of the building work one bedroom will have an en-suite facility. Staffing levels were suitable to meet the needs of the residents, staff were professional, warm and committed to the care of residents. The Commission had received no complaints in respect of the home or care provided. Records were well maintained accessed by the staff when necessary; policies and records complied with the National Minimum Standards. What the service does well: The staff and management at Bracken House provide a high standard of care for residents. The staff were competent and committed to the residents, which was demonstrated during the inspection. The areas accessed by the residents during the building work were well maintained by the housekeeping staff. Furniture and fittings were suitable for the client group. Following the building work there are plans to further update fittings in the bedrooms. The small garden at the side of the home contained a seat around the tree, tables and chairs, all used in the summer. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 7 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. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 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 Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Standard six is not applicable to this home. The documentation provided and made available to any person ensured that the relevant information would assist in making a placement. The practices of the home protected other residents, no person was admitted to the home without a full assessment of their needs. EVIDENCE: There were plans to further increase the information contained in the Statement of Purpose in 2006. This particular document, and where necessary the Service Users Guide will include an audio and Braille version. At the time of this inspection there were no new admissions planned due to the major refurbishment work. No person would be admitted to the home without a full assessment of their needs. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 10 Each of the residents were provided with the terms and conditions of the placement. Confirmation letters were part of the pre admission process. Bracken House had a trial period for both parties. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The sample of care plans identified that individuals health and personal needs were met by the committed staff group. Arrangements were in place to provide continued care from other professional agencies. The system used for the administration and storage of medication remained secure; training ensured the safety of residents. EVIDENCE: Care plans remained in a module format, the evaluations continued as required. The sample of two care plans clearly identified the progress of one person’s health following an illness. The other plan identified other professional agencies involved with her mental health. There are proposed plans to review the format of the care plans for 2006. During the inspection the District Nurse came to attend to one resident’s needs; she gave a good report of the professionalism of the staff, their politeness and assistance when requested. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 12 Medication was stored appropriately; the staff responsible were undertaking further training, for the safe handling of medicines. This training included the night superintendents. The staff on duty were respectful and assisted where appropriate. The atmosphere and interaction between the staff and residents was extremely positive and relaxed. One resident alerted the Head of Home to the inspector arriving and found it amusing to do so when challenged such is the interaction and openness in the home. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 The Head of Home and staff made arrangements for the residents to continue their life style; this was enhanced with a varied activity/social programme. Links with families was promoted with an open door policy for visiting. Residents at Bracken House were served a balanced diet prepared by qualified cooks. EVIDENCE: Arrangements were in place on a monthly basis for the residents to have the option of external entertainment. Bracken House had an activity organiser who creates interests to suit the ability of the residents. During the inspection the inspector evidenced a quiz-taking place, it was obvious that everyone involved was enjoying the session. The staff at Bracken House gives freely of their own time to raise funds for the comforts fund to provide the niceties of life for residents. A Christmas Disco had been arranged away from the home to raise funds, included will be a large raffle. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 14 Links with families were maintained, regular visitors were provided with the digital door number to access the home. Qualified cooks prepared food, the kitchen will be included in part of the building work, arrangements were already in place to cook and deliver meals. Residents had the option of Steak & Kidney pie, Ocean pie, Cauliflower cheese plus vegetables followed by Angel Delight, fruit. The tea would include home made cheese and onion lattice slice, an assortment of sandwiches, & shortbread. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The homes complaint procedure was displayed in the relevant required documents. This would enable any person to raise a complaint. Staff training ensured that residents were protected from abuse. EVIDENCE: Not all the present residents would be aware of the complaints process due to their frailty. The Commission had not received any form of complaint about the home or the care it provided. There was a system in place that would deal with any internal complaint within the time scale. A robust training programme internal to the home was for all the staff, followed by the foundation training and NVQ in Care. This positive training programme ensured that all the staff were aware of the need to protect residents from abuse. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 16 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 20 23 24 25 26 Bracken House management provided a comfortable home where residents can continue their life style. The on going monitoring of the homes environment continued. The home had excellent standards of hygiene. EVIDENCE: The location of the home was in a quiet part of an estate off the main road. Parking at the rear of the home was restricted at this time with the builders using the space. Every effort had been taken to ensure at all time a free access for any emergency vehicles. The part of the home undergoing major refurbishment was sealed off to residents and noise was at a minimum. The home was exceptional in its hygiene despite all the work. Accommodation is comfortable and well decorated. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 17 A sample of the bedrooms seen evidenced that residents were encouraged to bring in personal possessions. Good ventilation and heating was maintained throughout the home. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 18 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 28 29 30 Staffing levels were deemed satisfactory to meet the needs of the residents in an appropriate manner. All the required checks were in place to protect the residents. Staff demonstrated their experience and training in the manner in which they care for the residents. EVIDENCE: At any one time with the exception of nights there would be one of the management and four and a half whole time equivalent staff care assistants working with the residents; plus other management in the office. On occasions the Head of Home arranged for one of the staff extra to the total numbers, to go to the home for part of their shift where four residents had chosen to live during the building work. The home had ancillary support in the form of qualified cooks and housekeeping staff. Internal training for all the staff continued. There had been a positive input into internal training this year. Robust recruitment and pre employment checks ensured that residents were protected. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 19 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): 31,32,36,38 The management and the staff ensured that the residents were provided with quality care in a safe and secure environment. Regular audits and training would further enhance the environment and ensuring that the resident’s health and safety continued. EVIDENCE: The Head of Home had a relaxed approach; she had been in the caring profession for a number of years. The inspector from observations and discussions identified that the safety and care of the residents plus staff support were her priority. The ethos and ambience of the home was part of the commitment to the care of residents by all the staff. Staff were relaxed with the Head of Home and the inspection. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 20 Obligatory staff training continued with regular sessions planned for the staff. Regular supervision was on going, records were completed, the, inspector did not see these records. The annual matrix for training had been revised and simplified. The records in relation to the testing and training of the staff in respect of fire were current. The inspector was impressed with the commitment of monthly fire drills ensuring that all the staff were fully aware of the procedures. Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 21 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 4 X 3 4 3 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 X X X 3 3 4 Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 22 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. 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. Refer to Standard Good Practice Recommendations Bracken House DS0000028915.V262296.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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