Inspection on 25/01/06 for Brackendale House

This inspection was carried out on 25th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brackendale House 09/05/07

Brackendale House 12/04/06

Brackendale House 19/07/05

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 Mrs Dorothy Binns Announced Inspection 25th January 2006 09:45 Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 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 Brackendale House DS0000027481.V273553.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 Adults 18-65. 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. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 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 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) 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 DS0000027481.V273553.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Thirteen (13) service users with mental disorder may be accommodated. One (1) service user with mental disorder over 65 years of age, who is named in the Commission`s record may be accommodated. One (1) service user over the age of 65 years, with dementia may be accommodated. The total number not to exceed fourteen (14). Date of last inspection 19th July 2005 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 DS0000027481.V273553.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine announced inspection of the home and took approximately 7.5 hours. The registered manager of the home is currently on sick leave but an acting manager was present as was a representative from the head office of the organisation. Discussions took place about how the home was progressing and whether requirements made at the last inspection had been dealt with. Records and policies were examined and some parts of the building were toured. Four service users were seen in private and others were spoken to in the dining room. Three staff were interviewed. The Commission had sent out surveys to the home to be distributed to the service users but this had not been carried out. Further views from the service users were therefore not available. Not all the National Minimum Standards were inspected. What the service does well: What has improved since the last inspection? A noticeable improvement at this inspection was the relaxed atmosphere in the home largely due to changes in the group of service users. Service users were more animated and lively and there was more conversation. The food has improved with more fresh ingredients being used and more choice at breakfast. The premises were also cleaner and domestic arrangements have improved. The garden has been made much more attractive with flowerbeds and furniture and has benefited from the work of two of the service users who have much enjoyed it. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 6 The staffing arrangements are improved with a waking night staff on duty from 8pm giving more attention to service users in the evenings. Some improvements have been made to the administration of medication though further review is needed. 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. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 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 the following standard(s): 2 Service users’ needs and abilities are assessed before they come into the home so staff can support them properly. EVIDENCE: The assessment of the last service user admitted was examined and found to have detailed information about the service user. Their needs and abilities were recorded to help staff to know what support they would need. Information was also given from the mental health trust and the social worker. A second record showed an appropriate assessment had been made and the home’s own form is completed by the service user with the social worker. Risk assessments were in place to deal with specific areas of difficulty for instance self neglect or not eating. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 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 the following standard(s): 6, 7 and 9 The service users do have their needs and abilities and goals reflected in their care plans which are currently being overhauled. The service users do make their own decisions with regard to money but where they receive support from staff, new procedures have been brought in to ensure accuracy. Service users can live an unrestricted life but risk assessments are carried out if appropriate. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 10 EVIDENCE: Two care plans were examined. They were detailed and covered the varying areas where service users needed support. They detailed how the service users functioned in the house and what their goals were in terms of increasing their own independence. Care plans were reviewed and staff wrote progress notes on a daily basis. A key worker may have special responsibilities to see that the plan is achieved. (Staff confirmed that they were key workers for individual service users.) The manager is currently reviewing all care plans. The plans did not detail when there were restrictions on a service user, for example if cigarettes were controlled and this needs to be added showing the agreement with the service user and what the time limit will be for such a restriction. The financial records of the service users were examined. A theft has been reported recently (police involved) and it was particularly important to check the system. It was clear that the records were not kept in an organised way and five out of the nine looked at were in a mess with mistakes. Because of the theft, an audit had been carried out by the head office of the organisation and accounts had been corrected. The records were now being correctly kept and a change in access to service users money and maintenance of the records was brought in to ensure accuracy. It was accepted that the improvements have been made and the accounts will be checked at the next inspection to ensure the system is watertight. A change to the system is recommended however in that it is not clear what benefits are being cashed on a service users behalf by the company, and what happens to those benefits. A financial profile showing what they receive where it goes and what comes to the service users would clarify the position. Risk assessments were in place for those areas where there was a concern, for example someone not eating or where they were unable to stop other service users taking advantage of them. Details of how this would be dealt with by staff was laid out. There were no risk assessments for activities which might pose a risk to service users except in the case of a service user looking after their own medicine. Service users are all mobile and can go out unrestricted in what they do though the staff would consider any dangers if any area of activity gave concern. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 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 the following standard(s): 12,14 and 17 Only one or two service users are able to develop employment skills but more are occupied in tasks around the home. This is an area constantly under review. Service users are not always keen to take part in activities and staff are being more flexible in what they offer. Service users are offered a healthy diet which they enjoy and mealtimes are a positive experience. EVIDENCE: The home accommodates an older group of service users, most of whom do not feel up to working. One however does go to a farm group four days a week and another has done a computer course. One service user is contracted to do some chores around the house to help his confidence and two have been transforming the garden of the home. One helps with shopping for the home and buys the meat. This is good practice involving the service users in the household tasks. More can no doubt be encouraged and staff are looking for further opportunities. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 12 Service users can go out themselves and use the shops, pubs and facilities in the town. One person goes curling. Motivation is sometimes a problem and staff confirmed that they can plan an outing and when the time comes, no one wants to go. However one service user thought that more outings should be offered. The Home does have access to a car shared between three homes and staff confirmed they do go out. Some in house activities are offered but more on a spontaneous basis though one night has been set aside for a video and popcorn. Two staff mentioned taking service users out for a walk as part of their key working role in order to help the service users feel more confident. It is accepted that those with mental health problems do not want to be pressurised and the home has to balance this with the need to try and involve people in activities. The issue needs to be kept open with staff on the look out for appropriate opportunities. Where there has been success is in the involvement of service users in the household activities such as shopping and gardening and this is to be encouraged. The general feed back from the service users was that the food was better and that ingredients were fresher. Staff said meat was now obtained from a local butcher and this has proved much better. Very little processed food is now used and staff are preparing from fresh ingredients. The menus have been changed to provide more variety and generally were felt to be more enjoyable. One or two service users are involved in the kitchen and help to prepare the food. Staff also reported that breakfasts are better with toast and different spreads, as well as cereals and orange juice. This is an improvement since the last inspection. Service users were seen to be having lunch which was a choice of different flavours of soup with bread and fresh fruit and coffee. There was a jovial and relaxed atmosphere in the dining room with service users being friendly and conversational with the inspector. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 20 There have been improvements in the storing and recording of the service users’ medicines but a further review of how they are administered is required. EVIDENCE: The pharmacy inspector had asked the home to improve their procedures with medication and these were checked at this inspection. The acting manager is now carrying out a regular audit of the medication and spare medication to be retuned to the pharmacist is now being stored separately. The daily administration records were checked and found to be completed satisfactorily corresponding with the tablets in the pre packed containers. Drugs were appropriately locked up. The returns book was correctly recorded. Despite these improvements there was some concern regarding one or two service users who were not on occasion receiving their medication because they were out at the time of the medication round. There were questions as to whether the GP or pharmacist had been consulted about this or whether the timing of taking the tablets could be more flexible. It emerged that there were set times for medication and because of lack of trained staff there was little flexibility in the system especially in the late evening. Whilst some improvements had been made since the last inspection on record keeping, the inspector felt it necessary to seek the advice of the pharmacy inspector about these practice issues. It was agreed that a further review of practice was required to ensure that the needs of the service users were being met. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 22 and 23 A complaints procedure is in place and service users felt they could speak up to staff. Service users are protected from abuse by the homes procedures which are currently being tightened up. EVIDENCE: The complaints procedure is in the service users guide and posted up in the home. A complaints record is kept though no complaints have been recorded for a year. No complaints have reached the Commission. Service users said they were able to talk to staff and if they were worried someone would listen. Procedures regarding the protection of service users from abuse are in place and in the staff handbook. A whistle blowing policy is also available. Staff confirmed that they had received training about abuse except for the newest member of staff. The procedure is a national one reflecting the large organisation this home is part of. It would be helpful to have an addendum recording the local procedure and contacts in Norfolk so staff are sure how the matter should be dealt with. A recent theft of money has highlighted a loophole in procedures which is now being addressed. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 24 The Home provides a homely and comfortable environment for the service users who have access to the lounges and garden as well as their own single rooms. EVIDENCE: The home was looking much cleaner and efforts had clearly been made following the last inspection. Staff thought the cleaning was more methodical now. The lounge and dining room are comfortable and bright though a carpet would soften the lounge. A requirement was made at the last inspection for improvements in the back garden. It has now been much improved with the levelling of the ground, the rearrangement of the flagstones and the removal of rubbish. Largely through the enthusiasm of two of the service users the garden has been cultivated and looked much more attractive with flowers and sculptures. One of the service users said how much he enjoyed doing the garden and had even spent his own money on it though the manager will see that he is not out of pocket. He wants to carry on improving it and it was clear that his enjoyment of the work was contributing to his feeling fitter and more confident. The garden is now an attractive place for the service users to sit. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 16 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 36 None of the staff are qualified and training needs to be prioritised. Service users are supported by an effective staff team which provides good coverage of hours and a mixture of skilled and new staff. Recruitment procedures are not rigorous enough and are not protecting the service users. Staff are currently not as well supported as they should be. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 17 EVIDENCE: Two staff are currently studying for their NVQ. No staff have a qualification so far. The rota for the week of the inspection was provided for the inspection. It showed that there were always two staff on duty between 8am and 8pm and a waking night staff on from 8pm. The manager is extra on three days a week. Staff provide all the support to service users and also do the catering. One service user is also contracted for a further ten hours for individual support. Taking all that into account, the hours were satisfactory and the provision of a waking staff giving service users someone to talk to in the evening and at night is a considerable improvement. Cleaning hours during the day are light with only five provided when 25 would be expected. However the waking night staff have some cleaning duties and if they do three hours of domestic work a night then this would provide the additional hours. There are both male and female staff members and some are more experienced than others. Some new staff have joined the team and the group is still consolidating. However the impression given by the staff and service users is that staff give good support. Three staff files were examined and it was found that recruitment procedures are not rigorous enough. Two of the files showed that the staff member had started not only before the criminal records check had been made but before the fast track protection of vulnerable adults list had been checked. This is not acceptable and is placing the service users at risk. One staff had also been recruited before any of the references were received. Recruitment procedures were also criticised in the last report and it is disappointing that practice has not improved. A requirement has been made for immediate changes in recruitment procedures. The system of offering staff one to one meetings with their manager (supervision) where they can discuss their work has not been sustained and needs to get back on track. With the manager off sick and an acting manager in place it has not been easy to maintain all systems but to promote good practice this needs to be in place especially with the recruitment of new staff. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 18 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 Service users feel they are listened to in a general way, but a quality assurance system where they are asked anonymously about their views of the home and where the home respond is yet to be put in place. The health and safety of service users and staff are promoted by the policies and good housekeeping of the home. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 19 EVIDENCE: The quality assurance system is currently being overhauled and as such there was little evidence in the home showing what it included. A property audit was seen showing what needed to be done in the following year to the building. A training report was seen showing the training schedule for the current year. There were no quality standards showing what would be measured nor any results of surveys carried out amongst the service users and their advocates and people who come into the service. However the organisation is preparing such a system and it is expected that this will be in place at the next inspection. A recommendation has been made to ensure the system is local to the home and anonymous so service users can speak up. A reluctance was detected from service users about surveys going to head office as they did not feel listened to and had never received feedback following previous surveys. The health and safety procedures and policies of the home were examined. These were available and are also listed in a staff handbook. The fire record also showed that fire tests and drills were carried out regularly and that the fire system receives an annual inspection. Two fire extinguishers were checked at random and found to be up to date. Gas and electrical testing was up to date as was the testing of the water temperature gauges. The manager confirmed that the boiler had recently been serviced. Staff files confirmed that moving and handling training, COSHH and food hygiene were provided and was included in the staff induction course. An accident book is kept. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 20 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 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 2 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x LIFESTYLES Standard No Score 11 x 12 3 13 x 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 1 3 1 x 1 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Brackendale House Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x DS0000027481.V273553.R01.S.doc Version 5.0 Page 21 Yes 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 YA34 Regulation 19(1)(b) Requirement Appropriate recruitment procedures must be used to ensure that service users are protected. Previous timescale 19/07/05 not complied with The registered person must take steps to ensure adequate arrangements are in place for the administration of medicines prescribed for service users at the home. Staff must be appropriately supervised. Timescale for action 28/02/06 2 YA20 13.2,13.4 19/07/05 3 YA36 18(2) 31/03/06 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 Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 22 1. 2. 3. 4. YA7 YA23 YA32 YA39 It is recommended that a financial profile is recorded for all service users whose benefits or money is administered by the home or organisation. It is recommended that the local procedures and contact numbers for the adult protection unit are included in the procedure for the home. It is recommended that NVQ training is given priority so more staff can be trained. It is recommended that the quality assurance system is further developed to ensure it is local to the home, has anonymous surveys and provides an action plan for further development. Brackendale House DS0000027481.V273553.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Norfolk Area Office 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 DS0000027481.V273553.R01.S.doc Version 5.0 Page 24 - 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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