Inspection on 24/05/05 for Brackenthwaite

This inspection was carried out on 24th May 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

Brackenthwaite 17/07/06

Brackenthwaite 19/01/06

Brackenthwaite 22/09/04

Brackenthwaite 04/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Brackenthwaite Senhouse Street Whitehaven Cumbria CA28 7ES Lead Inspector Elaine Brayton Unannounced 24 May 2005 at 9.30am 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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Brackenthwaite Address Senhouse Street Whitehaven Cumbria CA28 7ES 01946 852561 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) Cumbria Care Susan Meyers Care Home 30 Category(ies) of OP - Old Age registration, with number DE(E) - Dementia, over 65 of places Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. A maximum of thirty older people (30 OP) including three people over the age of 65 with dementia (3 DE(E)) 3. The staffing levels for the home must meet the Residential Forum Care Staffing Formula for Older Adults. 4. When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger rom when one becomes available.. Date of last inspection 22 September 2004 Brief Description of the Service: Brackenthwaite provides accommodation and care for up to 30 older people, 3 of whom may have dementia. The Home is situated in the centre of Whitehaven, close to all the towns’ services and amenities. Brackenthwaite is operated by Cumbria Care, an internal business unit of Cumbria County Council. The accommodation is provided on three floors and there is a passenger lift for ease of access. The Home is divided into three separate living areas. On the ground floor there is a lounge/dining room with small kitchen, plus a further quiet lounge with bedrooms, toilets and an assisted bathroom nearby. Also on the ground floor is another lounge/dining room, and the bedrooms and bathroom for the people who use this lounge are on the third floor. There is a lounge that can by used by those people who wish to smoke, and a spacious entrance hall with seating. On the second floor there is a lounge/dining room with small kitchen area, with bedrooms, toilets and assisted bathroom nearby. There is a garden area to the rear of the home with raised flowerbeds, a greenhouse and seating. There is parking to the side of the home. Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home and took place over one day. The Pharmacy Inspector, Angela Branch was present throughout the day looking at all aspects of the medication systems operating in the home. There were 26 residents living in the home on the day of the inspection. During the day time was spent talking with service users, individually and in small groups. All parts of the home were visited and the manager and care staff on duty were spoken to. What the service does well: What has improved since the last inspection? What they could do better: The medication administration records showed some omissions of signatures when administering medication. Staff must always sign at the time they administer medication to residents. Some communal toilets did not have any paper towels and one toilet any soap, these should always be available in the toilets. Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 6 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. Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,5 The admission procedures of the home are thorough and ensure residents needs can be met before they move into the home. EVIDENCE: The home has a Statement of Purpose, which is available to residents, prospective residents and any other person visiting the home. It provides important information about the services and facilities available in the home. The assessments looked at during the inspection contained information about the care needs of the prospective resident, and together with the preadmission meeting allowed senior staff to judge if the home could adequately meet the persons health and social care needs. Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The care planning system are clear and consistent and ensure residents care needs are met. There are systems in place to ensure residents receive their medication as prescribed. EVIDENCE: A selection of care plans were looked at during the inspection and they contained comprehensive information about the care needs of the resident. The plans also included risk assessments and moving and handling assessments, they were reviewed regularly and residents said that they are involved in the drawing up of their care plan. Details are recorded of any healthcare appointments or visits to assist in monitoring resident’s general health. The home managed medicines safely. Staff were well informed of the medicines they administered. The records for administration were generally good but on 22 May 2005 there were a number of signatures for administration were missing for a number of residents. Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 10 Residents were able to take their own medicines where this was shown to be safe and appropriate. Those that took their own medicines were assessed regularly to ensure this was safe. The administered dose of a medicine called warfarin was not always stated on the medication record although the home logged all changes to the dose received from the GP after blood tests were done. The manager was introducing a new recording system to safely manage this medicine. The system was implemented shortly after the inspection to ensure that all results and dose recommendations were received after a blood test and recorded properly. The inspector was told of an incident where the home did not receive necessary information about dose recommendations and the system enabled them to identify this and take necessary action. This is an example of good practice. Medicines were kept neat and tidy. The manager was requesting medication reviews for residents who required them. Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 Residents maintain links with their relatives and friends as they wish, and are encouraged and assisted by staff to retain control in their day to day life through making their own choices. EVIDENCE: Residents said that they made their own decisions about how they spent their day, choosing to spend time in one of the communal areas or in their own private room. Meals were selected from a small menu, and people had an opportunity to participate in activities such as bingo and board games. This allowed people to keep some control over their life. Residents said that they could receive visitors at any time, they were offered refreshments and could spend time in one of the communal areas or in the person’s private room. The home had recently introduced a newsletter, which will be published at regular intervals throughout the year. Residents and visitors to the home are encouraged to submit items to be included, and this is proving popular with people. Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a satisfactory complaints procedure, which is displayed in the home, and residents are provided with their own copy. EVIDENCE: Each resident and their relative is provided with a copy of the homes complaint procedure on admission to the home, so people are clear about their options should they wish to make a compliant. Residents spoken to said they would know what to do and who to speak to if they wanted to complain about anything, and believer that their complaint would be dealt with properly. Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,23,24,26 The communal and private accommodation is decorated, furnished and maintained to a good standard providing pleasant and comfortable accommodation for residents. EVIDENCE: The home is comfortable and homely and is well maintained, with maintenance records kept. A number of areas in the home had been decorated, including some communal areas and some bedrooms; new carpets had been purchased along with some dining chairs and lounge chairs. Residents said they liked their bedrooms, thought they were small but comfortable, and liked being able to personalise them with their own possessions. The home was clean and hygienic on the day of the inspection. Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Staff recruitment is robust, and ensures that sufficient numbers of staff are available with the necessary skills to meet the needs of service users. EVIDENCE: The staff on duty were able to meet the needs of the residents currently living in the home. As well as care staff there were staff to do the cooking and cleaning, and a member of staff with responsibility for arranging activities for residents. Each night there are two members of waking night staff on duty. Residents said they thought there were enough staff on duty, and said they were attended to promptly when needing assistance. More than half of the care staff had completed a National Vocational Qualification in care, and all staff had completed training in key areas such as infection control and moving and handling. The training develops the knowledge and skills of the staff, which improves the quality of the care provided. Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,36,37,38 The manager is experienced, competent and ensures there are satisfactory systems in place so that the home operates in a way that protects the health and safety residents, staff and visitors. EVIDENCE: The manager has many years experience in running a care home, and is halfway through completing the Registered Managers Award. This will enhance her skills and knowledge which will impact positively on how the home operates. All staff are receiving individual supervision on a regular basis, and this helps to make sure staff have the required skills to provide care to residents in line with the homes policies and procedures. Records looked at demonstrated the tests and checks carried out to provide a safe environment. Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 x x 3 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x 3 x 3 3 3 Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 17 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 op9 Regulation 13(2) Requirement All MARs must be signed for administration at the time of administration and the dose of warfarin must be recorded. Timescale for action 01.07.05. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith, Cumbria CA11 9BP 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 Brackenthwaite F58 F10 s36544 brackenthwaite v220770 230505 ui stage 4.doc Version 1.30 Page 19 - 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. 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