Inspection on 19/07/05 for Brackendale House

This inspection was carried out on 19th July 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

Brackendale House 09/05/07

Brackendale House 12/04/06

Brackendale House 25/01/06

Brackendale House 15/12/04

Brackendale House 07/06/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 Brackendale House 1-3 St Peters Road Sheringham Norfolk NR26 8QY Lead Inspector Dorothy Binns Announced 19 July 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Brackendale House Address 1-3 St Peters Road, Sheringham, Norfolk. NR26 8QY. 01263 824995 01263 824995 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) Prime Life Limited Lisa Jane Beasy Care Home 14 Category(ies) of Dementia - over 65 years of age (1), Mental registration, with number disorder, excluding learning disability or of places dementia (13), Mental Disorder, excluding learning disability or dementia - over 65 years of age (1) Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Thirteen (13) service users with mental disorder may be accomodated. 2. One (1) service user with mental disorder over 65 years of age, who is named in the Commissions record may be accommodated. 3. One (1) service user over the age of 65 years, with dementia may be accommodated. 4. The total number not to exceed fourteen (14) Date of last inspection 15 December 2004 Brief Description of the Service: Brackendale House is a private residential care home registered to accommodate 14 service users recovering from mental illness. All the bedrooms are single and on the ground, first and second floors. There are two self contained units on the third floor where two service users, moving towards independence each have a bedsitting room, kitchen and bathroom.The Home is located within easy reach of the facilities of the seaside town of Sheringham.The Home is owned by Prime Life, a national organisation with homes throughout the UK and the current manager was appointed in 2003. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection to see how the Home operated on a normal day. A pharmacy inspector was also in attendance. The purpose of the inspection was to see how the service users were getting on and to look at some of the records and policies in the Home. Six of the service users were spoken to and two of the staff were interviewed. The pharmacy inspector checked the medication systems. What the service does well: What has improved since the last inspection? What they could do better: Whilst it is accepted that it is difficult to motivate some people, the Home should offer more outings and trips out to the service users on a regular basis. A better choice of food should be offered at breakfast and extra drinks available for the latecomers. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 6 Training could be better with more staff studying for a national care qualification. Recruitment procedures need to be tighter. There needs to be a more rigorous cleaning routine and safety in the garden should be attended to. The pharmacy inspector would like some improvements in the medication systems. 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. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The service users are assessed prior to admission to make sure the Home can cater for their needs. EVIDENCE: Two care records were chosen at random and found to have detailed information about the service users needs and abilities. The service user completes the application from so that the Home is aware of their wishes and need for support. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9 Service users are involved in forming their care plan and have their needs assessed so staff look after them properly. Risk management strategies are agreed within the context of the care needed. Service users feel they are able to go about their lives as they want and make their own decisions. They manage their own finances even though they need some help. EVIDENCE: Two care records were selected at random and found to have details of the care needs of the service users with information about the assistance they would need from staff. Risk assessments were in place for those areas where there was a concern, for example someone who was not eating. Daily reports by staff were detailed and picked up on these areas of care showing that they were monitoring the situation. This is good practice. The risk assessments did need to be updated however and regular reviews are recommended. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 10 The financial records of the service users were checked as some have their money looked after by the Home. Two were checked against the cash held and cross referenced with their bankbook and receipts and found to be correct. Financial profiles have also been recorded to show exactly how the Home looks after their money. This is good practice. One service user was seen to come to the office for some of his money, ask for how much he had and then make a decision about how much he needed. This demonstrated good practice and showed he was in control. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) ,13,14,15,16 and 17 Overall the service users are able to get out and about when they want to and enjoy the local community. Most are happy with a quiet life but more outings would be appreciated. Contact with family is encouraged and supported. The routines are flexible and the service users feel comfortable in the Home. In general the service users liked the food but would like a bit more at breakfast and access to drinks especially in the morning. EVIDENCE: The Home accommodates an older group of service users who are not able to work though some opportunities for education have been taken such as computing classes and creative writing. One attends a rehabilitation centre twice a week. Service users spoken to were happy with a quiet life and did not feel up to going to classes or voluntary work. This is something the manager monitors to ensure that service users are given all the chances they need. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 12 Service users do use the community a lot and several are out and about every day. One service user said she was out every day to the local shops and café but also uses public transport to go further afield to Norwich and North Walsham. Another service user was on his way to the pub where he said he was a regular visitor. Another person does some shopping for the Home and runs errands for staff. One talented service user is in a writing group and writes for the local paper. He also attends poetry reading sessions. There was evidence in the files that staff also take service users out occasionally if they need some support. Service users are encouraged to pursue their own hobbies and there was evidence in one service user’s room of her interest in music and in knitting. Activities are dependent on the service users being interested and staff said it is quite hard to motivate them. However one person helps with the cooking and another runs errands for the staff. One staff said how he provides wood for one service user as he likes to make things. This is very good practice. At least two of the service users spoken to said they would like more outings and it is recommended that staff continue to offer trips out even with only one or two service users participating. It is accepted that some will express an interest and then not want to go but it is worth it for the few who do. There is no holiday arranged this year and one service user thought they should have outings instead. This is something the manager needs to take up. There was evidence in the files and in conversations with the service users that they had contact with their family and were supported to visit them. Service users can also maintain personal relationships. Service users gave different times for getting up and said they went to bed when they liked. They can also have a bath when they like though one or two need help with this. They have their own door key if they want. They were also seen to be free to wander about the Home and use the garden and communal areas or their rooms as they liked. Service users were well aware of the tasks they were expected to do mentioning their laundry day and making their own bed. The rules on smoking were also understood with some smokers in the garden on the day of the inspection.(a fine day). Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 13 All the residents spoken to enjoyed the food. There is not a dedicated cook and care staff do the catering but this was not seen as a disadvantage. One staff confirmed that fresh meat is bought every day and fresh fruit is available. There are two choices at the main meal and a snack at lunchtime. Service users help themselves to breakfast which is available in the residents kitchen. However only cereals were seen in the cupboard and the service users confirmed that that is all that was available. Two said they would like to have toast but it was not available. Staff confirmed that they could have toast if they asked for it but it is recommended that this is offered as well as a variety of spreads. There is a big fried breakfast late on a Sunday morning which the service users enjoy. There is a restriction on service users helping themselves to drinks because of previous difficulties. Drinks are now served on a regular basis in the dining room. However for those who get up early or late, there is no drink and this needs to be remedied. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and20 Service users are helped appropriately and their health needs are attended to. Action is required to address several areas of medicine management in order to improve the safety of the homes practice and thereby protect the health and welfare of individual service users. EVIDENCE: Only one or two service users need support with their personal care. Most deal with their own and said they can have a bath when they like. They choose their own clothes and can dye their hair or express their individuality as they choose. The Home does have two male carers allowing service users a choice as to who helps them. Not all of the elements of standard 19 were looked at but the files showed evidence of attendance at the dentist and the GP surgery. They also showed that staff were monitoring the weight and food intake where required and watched the mood and health of the service users. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 15 The inspection of standard 20 was simultaneously conducted by specialist pharmacist inspector Mr M Andrews. He found that the home has a simplified system for medicine ordering, administration and record-keeping, however, there were areas of inadequacy in record-keeping practice impinging on safety which requires remedial action. He suggested that consideration should be given to the implementation of regular auditing of records in order to promptly identify such inadequacies arising. The inspector was satisfied that medicines were adequately stored and secured. He observed medicine administration practice and identified areas requiring improvement to enhance safety. He also identified medicines available in the medicine cabinet that were no longer in use and was concerned of the risk that they may be erroneously administered. It was recommended that the home considers making arrangements for the separate and temporary storage of medicines no longer in use prior to their disposal to the pharmacy. Members of staff authorised to handle and administer medicines have received training provided by an external source. The inspector suggested that a programme of further and more advanced training is implemented. A detailed pharmacy inspection report has been sent to the registered provider and is available subject to request. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were inspected. EVIDENCE: Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,28 and 30 Service users have a comfortable and homely environment with pleasant communal space and garden. The Home needs more adequate cleaning however and some attention to safety in the garden. EVIDENCE: The premises are comfortable and bright and cheerful and provide easy access to local amenities and transport. They are accessible to all service users as all are mobile. Furniture and fittings are domestic and attractive. The Home is however dirty in parts and needs to be more adequately cleaned. The service users kitchen was dirty around the tiles and on the skirting board. The dining room skirting board was full of dust. One service user’s room was very dirty with dust thick on the skirting board and the windows and sink were very dirty. A spring clean is needed. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 18 The Home has a comfortable lounge which has been considerably improved since the last inspection with new chairs and curtains and more ornamentation. The lino floor remains but the room is much more attractive for the service users. The dining room is also bright and cheerful and has a sitting area and the service users’ kitchen. French doors lead to the garden which is very pleasant with plants and garden furniture. There is however an area which is unsafe for the service users and needs to be improved. Tarpaulin is sticking up beneath a shingle area causing a tripping hazard. This needs attention. The laundry was seen to contain a domestic washing machine and a tumble drier which service users are able to use for their weekly wash. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34 and 36 Service users feel well supported by staff but they would benefit from further training. The recruitment procedure is normally rigorous but on this occasion there was a lapse that could pose a risk for the service users. Staff are generally well supported with a manager who makes herself available for them. Documentation on formal supervision should be better. EVIDENCE: Two staff files were inspected for evidence of training. Both contained induction training and certificates showing first aid and food hygiene certificates. One had a management of medicines training. No staff have completed their NVQ2 however though one staff is currently studying for that qualification. Two staff would like to train but are experiencing a delay. The Home is failing to meet the standard in this area and should pursue the possibility of training as a high priority. Staff seen at the inspection were committed and understanding about the service users who spoke well of them and felt well supported. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 20 A rota for the week of the inspection was produced and showed that there are always two staff on duty between 8am and 8pm and one staff on duty after that. This is in addition to the manager’s hours and a cleaner who comes three times a week. Even though care staff have to do the catering, these hours are good. The fourteen hour shift which this Home continues to use on five days a week is considered very long by the Commission. There has not been too much turnover of staff and the staff team has both male and female members reflecting the make up of the service users. The recruitment procedures of the Home were examined and evidence of references, application forms and identity checks were in place. One staff had been taken on before her criminal records check was returned though a POVA check had been made. However this member was rostered to be on duty by herself on one day when she should only be working under supervision until her criminal record check is through. This is not satisfactory and the manager agreed at the inspection to change the rota. The manager was advised that in future the criminal records check must be available before employment. The manager said that she was having regular supervision sessions with staff though there was no evidence of this found. The inspector was willing to take the managers word but advised that documentation should be up to date. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38 and41 The management style in the Home supports the service users who feel they can express an opinion and that they will be listened to. The records in the Home are satisfactorily maintained, ensuring that the service users are monitored and safeguarded. EVIDENCE: Service users speak well of the manager and mentioned her as the person to speak to if they had a problem. She regularly has house meetings with the service users and they referred to these when speaking to the inspector. The manager also has an open door policy with staff. She was registered in 2003 and is currently studying for her NVQ4. She also has the support of a managerial structure from head office. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 22 Not all the records required for regulation were inspected but those requested were in place and properly maintained except where specific comments have been made in the relevant standard. A requirement had been made at the last inspection for regulation 26 visit reports to be in place. These are now being documented and the most recent one was forwarded to the inspector. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 2 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 2 3 3 2 Standard No 31 32 33 34 35 36 Score x x 3 2 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Brackendale House Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 x x I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 24 No 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. 2. Standard 24 28 Regulation 23(2)(d) Requirement Timescale for action 31.8.05 31.8.05 3. 32 4. 20 The registered person must ensure that all parts of the home are be kept clean 13(4) The registered person must ensure that unnecessary risks to the health and safety of the service users are identiified and as far as possible eliminated. In this respect the back garden has some trip hazards. 19(1)(b) Appropriate recruitment procedures must be used to ensure that service users are protected. 13.2,13.4, The registered person must take 17.1(Sche steps to ensure adequate dule 3) arrangements are in place for the receipt, administration, record-keeping and disposal of medicines prescribed for service users at the home. Immediate and ongoing. Immediate and ongoing 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 Good Practice Recommendations I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 25 Brackendale House 1. 2. 3. 4. 5. Standard 6 14 17 32 36 It is recommended that the risk assessments are reviewed regularly to ensure they are up to date and relevant. It is recommended that more outings are arranged for those service users who want them. It is recommended that more choice is offered to the service users at breakfast and that drinks are available. It is recommended that NVQ training is given priorty so more staff can be trained. It is recommended that the supervision on staff is carried out six times a year and documented. Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 3rd Floor, Cavell House St Crispins Road Norwich NR3 1YF 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 Brackendale House I55 S27481 Brackendale House V240209 190705 Stage 4.doc Version 1.40 Page 27 - 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!