Inspection on 09/05/07 for Brackendale House

This inspection was carried out on 9th May 2007.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brackendale House 12/04/06

Brackendale House 25/01/06

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 Maggie Prettyman Unannounced Inspection 9th May 2007 09:00 Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 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.V339400.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 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.V339400.R01.S.doc Version 5.2 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited Shane Haines 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.V339400.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. The total number not to exceed fourteen (14). Date of last inspection 12th April 2006 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 bed sitting 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. The current manager is new, but not yet registered. Prospective service users have access to a guide to the home and CSCI inspection reports are available on the notice board of the Home. The current range of weekly fees is £307 - £405. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the home took place over the course of one day. Prior to inspection the Commission received some feedback questionnaires. Previous reports and records held by the Commission were also studied. During the visit six people living in the home were consulted and three staff members and the unit manager were spoken to or observed by the inspector. Written records in the home were also checked and a full tour of the premises was undertaken. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out using information from previous inspections, information from the providers, the residents and their relatives as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the home and current judgements for each outcome group. What the service does well: Brackendale House is a homely and friendly place where people can live according to their personal choice and wishes. A new manager has been appointed who is making some very important improvements to the way that the home is run. The staff are trained and caring. Good information is available to people to help them decide if it is the right place for them to choose to live. People are supported to make individual choices and to have their needs met. The lifestyle of the home reflects the wishes of the people living there. Community links are fostered and maintained, and the routines of the home are flexible and accommodating. Personal and healthcare support is given in a respectful, friendly and practical way. People’s comments and complaints are listened to and acted upon. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Brackendale House is a home that is striving to improve its service. There is still much hard work to do, but the manager and his team speak confidently of expected progress. Some areas of improvement were identified during the inspection. Unfortunately a lack of Adult Protection training for staff, which is a requirement of the standards, has led to the overall assessment of this home being reduced. • • • • • • A requirement has been made for all staff to receive adult protection training The initial needs assessment could be better documented The work to improve care plans should be completed as soon as possible Better educational and occupational resources could be identified Comments, minor complaints and compliments could be recorded and audited The planned refurbishment of the home should be completed as soon as possible Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 8 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.V339400.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 People who use the Service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. People who plan to use the service and their representatives have the information that they need to choose a home. They have their needs assessed before coming to stay to ensure that the home is suitable for them. EVIDENCE: The new Service User Guide and Statement of Purpose form an up to date information pack which is given to prospective residents and their families. The manager of the home visits people who are thinking about coming to the home and gets information from them, their families and other professionals to assess how well the home can meet their needs. Files demonstrated that assessments take place, but that there could be better documentation of this. A recommendation has been made to this effect. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8 and 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives and play an active role in planning the care and support they receive. EVIDENCE: Examination of people’s individual plans of care demonstrated some variability in the quality of recording of care planning and review. The new manager is working to achieve consistency in this area. A recommendation has been made to this effect. Daily records are kept as well as separate health care records to assist with review. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 11 Discussions with people living in the home as well as observation of the daily life of the home during the inspection demonstrated that people are supported to make individual decisions and choice about their lives. People were observed choosing their rising time and coming and going from the home as they wish. Significant changes have taken place since the last inspection with residents meetings now taking place regularly. People living at the home confirmed that these enable them to raise issues and to plan the way that the home is run for their benefit. An example of an issue raised by residents being addressed through a staff meeting was seen. Risk assessments were seen in people’s individual files. Staff were observed offering appropriate support and guidance to enable people to take managed risks during the inspection. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15, 16 and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home are able to make choices about their lifestyle and are supported to develop their life skills. The home is working towards ensuring that social, educational, cultural and recreational activities meet the needs of people living there. EVIDENCE: Two people living at the home are involved in voluntary work in the local community. The new manager is exploring further potential community and educational resources for people to access. A recommendation has been made to this effect. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 13 Changes to the way that the home is run have meant that people are now actively involved in shopping for provisions for the home and for and personal items in the local community. People were observed during the inspection going out and about in town and using local facilities. Most people chose to register to vote at the recent elections. Activities at the home have a focus on life skills and personal involvement in the daily life of the home. People are now encouraged and enabled to participate in daily tasks as a route towards developing confidence and reestablishing life skills. People have achieved food hygiene certification to assist with preparation of food for the group, and are also supported to maintain the cleanliness of their rooms and the communal areas of the home. The manager is in the process of acquiring an allotment, so that people can be involved in the production of fresh vegetables for the kitchen. During the inspection one person was away staying with a family member. People said that their family and friends are welcome to visit the home at all times. The manager was able to cite two examples of work conducted to maintain family relationships. People living at the home confirmed that staff respect their privacy and always knock on doors before entering. People were observed being involved or supported to do their laundry and help with the chores around the home. Post was seen left unopened in people’s individual pigeonholes. Names of choice were used. Staff on duty and visiting the home during the inspection interacted with people in a respectful and compassionate way. Significant changes have been made since the last inspection with regard to how the food that people eat is chosen and prepared. People express daily choices and staff support them to prepare food. A new kitchenette has been provided which gives people the opportunity to make simple snacks and drinks. The dining room has been reorganised to make it more friendly and easier to use. Fruit juices and fruit are now available at all times to encourage healthy eating. People living in the home said that the food is better than it has been before and talked about healthy eating options. The manager took information offered during the inspection to explore MUST nutritional assessment training for staff. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health care and personal care support that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: People living at the home are given support to look after their own personal care. People confirmed that their daily routines are flexible and that they choose their own clothes and appearance. People’s ongoing health care needs are recorded in their individual files. Records demonstrated that regular input and nursing support is given by a CMHN. People choose a GP from the local Surgery. Dental services are accessed from NHS direct services at Cromer. Opticians are available on the local high street. A Podiatrist is available locally. Records demonstrated annual review with the GP. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 15 The home has significantly improved its system of medication since the last inspection. All requirements and recommendations have been implemented. Records showed that self-medication risk assessments are renewed monthly. PRN records were found to be accurate. New lighting has been installed over the medication trolley. Evidence of full medicine audit was seen. All staff are trained in handling medicines and the training has a 2-year expiry date. Drugs were found to be correctly stored, and records were accurately kept. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 People who live in the home experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home are able to express their concerns and complaints and action is taken. The home has not yet given all staff comprehensive adult protection training, though some training for senior staff is imminent. EVIDENCE: Evidence at the home as well as reports made to the Commission demonstrate that the home responds to complaints made by people living there. Further evidence during the inspection of action taken by the manager in response to an informal complaint was seen. The home is not currently recording and auditing comments, minor complaints and compliments about the service. A recommendation has been made in this respect. The whistle blowing policy and procedure is clearly displayed in the hallway. Most staff have been trained in de-escalation and non-interventive techniques of working. POVA training is booked for two senior staff in the near future. A requirement for adult protection training to be given to all staff has been made. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people to live in a safe and comfortable environment as independently as they wish. The home is in need of its planned refurbishment. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 18 EVIDENCE: The home itself is suitable for its purpose and is well maintained in terms of fixtures and fittings. It is safe, clean, fresh and comfortable. It is close to local amenities and suits the lifestyle of people living there. The houses are indistinguishable from others on the street. Furnishings are appropriate and a recent fire service inspection has been complied with. However, the home clearly needs urgent refurbishment. The programme has been started with the purchase of new curtains. A survey of the home in February by the provider organisation has identified many areas in need of redecoration and renewal, and work is planned for the near future. A recommendation has been made to this effect. A tour of the premises demonstrated that the home is clean, pleasant and hygienic. The laundry area is adequate and people living in the home are encouraged to do their own washing and cleaning regularly with support if needed. The residents also help out with cleaning and tidying of communal areas. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home are carefully vetted. They are trained and skilled and are in sufficient numbers to support the people who use the service. EVIDENCE: Inspection of staff files demonstrated that people recently recruited to work in the home have a background in providing care or therapeutic services. Observation of staff during the inspection, as well as feed back from people living in the home, showed that warm, open and friendly relationships exist between staff and residents. An air of respect and supportive concern was present. The manager is working to address the shortfall in NVQ qualification in the staff team, and is in the process of supporting three further workers to achieve this. Inspection of staff records demonstrated that great care is taken to ensure that staff are fully vetted prior to their employment. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 20 The organisation has worked to address training shortfalls since the last inspection. Evidence of induction training was seen. Training courses are planned and a schedule of training required and expiry dates is held. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 38, 39, 41 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management of the home is based on openness and respect and a new quality assurance process has been implemented. EVIDENCE: The new manager of the home is experienced and competent. He is in the process of registering with the Commission. He is shortly to complete his NVQ level 4. He has autonomy to run the home and to manage budgets. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 22 The home is developing an atmosphere of open, positive and inclusive attributes. The manager works “on the floor” leading by example. Staff feel well supported and confident in his management style. A new independently completed quality assurance process has been implemented since the last inspection. Recommendations made as a result of this have been implemented. The new manager has improved record keeping in the home and has dispensed with the “Message Book” to ensure that records are kept only in resident’s personal and private files. A tour of the premises and inspection of maintenance and safety records demonstrated that hazardous substances are correctly risk assessed and stored. Regular servicing and maintenance checks are recorded. Window restrictors are in place on upper floors. Records showed that mandatory training is in place for staff. Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 3 3 X Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 24 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. 1 Standard YA23 Regulation 13.6 Requirement All staff working at the home must be trained in Adult Protection to ensure that the possible signs and symptoms of abuse are known, and that action can be taken if the need arises. Timescale for action 31/07/07 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 2 3 4 5 Refer to Standard YA2 YA6 YA12 YA22 YA24 Good Practice Recommendations It is recommended that a more comprehensive record of needs assessments be kept by the home. It is recommended that the work on improving the consistency and review of care plans is completed as soon as possible It is recommended that the home works to develop further occupational and educational opportunities for people living at the home. It is recommended that comments, minor complaints and compliments about the service are recorded and audited to identify any underlying patterns and trends. The planned refurbishment for the home should be DS0000027481.V339400.R01.S.doc Version 5.2 Page 25 Brackendale House completed as soon as possible Brackendale House DS0000027481.V339400.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V339400.R01.S.doc Version 5.2 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!