CARE HOMES FOR OLDER PEOPLE
Brackley Cottage Hospital Pebble Lane Brackley Northants NN13 7DA Lead Inspector
Mrs Sarah Smart Unannounced Inspection 3rd May 2006 09:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Brackley Cottage Hospital Address Pebble Lane Brackley Northants NN13 7DA 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) 01280 702388 01280 700329 Brackley Hospital Trust Claire Mansfield Care Home 6 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. 6. The total number of service users must not exceed 14. The 14 service users will be in the category of OP No-one falling within the category of intermediate care may be admitted to the home when there are 9 persons in this category already accommodated within the home. No-one falling within the category of OP receiving nursing care and not intermediate care may be admitted to the home when there are 5 persons in this category already accommodated within the home. The beds located in the multi bed rooms must only be used for service users receiving intermediate care for rehabilitation, and must not be used for any other category, including palliative care. Service users whose anticipated stay exceeds 8 weeks may not be admitted into the intermediate beds. 6th December 2005 Date of last inspection Brief Description of the Service: Brackley Cottage Hospital provides nursing and intermediate care to 14 service users. It is situated close to a park, and close to amenities in the market town of Brackley. Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced inspection was undertaken between the hours of 09.45 and 2pm. Preparation for the inspection included, review of the previous inspection report, requirements and recommendations, and took approximately 4 hours. The primary method of inspection used was ‘case tracking’. This involves selecting a number of service users and tracking their care and experiences through review of their records, discussion with them, the care staff and observation of care practices. The following areas were covered during the inspection: case tracking, medication, sample of policy review, staff rota, staff files, quality assurance, staff supervision, accident records, complaints records, tour of the premises, previous requirements made, and staff and service user interviews. Two service users were case tracked, and were selected during the tour of the premises. Three staff members, plus the manager, were interviewed at length, and several others briefly, whilst four service users were spoken to in detail. The inspector also had the opportunity to speak to one of the trustees of the hospital. What the service does well:
The needs assessments were recorded to a high standard. Plans of care for service users receiving intermediate care were satisfactory. Medication was managed to a high standard. Service users stated that their privacy and dignity is maintained, and their visitors are welcomed into the home. Complaints handling is satisfactory, and service users are adequately protected by the policies held in the home. The environment of the home is satisfactory, and was clean and tidy at the time of the inspection. The kitchen was well organised and clean. Staffing levels were satisfactory, and recruitment of paid staff was acceptable. Staff training appeared to be up to date. Communication between staff and service users was noted to be pleasant and appropriate at all times during the inspection, and service users stated that they staff are very nice. The home is managed to an appropriate standard. Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 6 Quality monitoring had been recently carried out, and received positive feedback. Records relating to health and safety were all satisfactory. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 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 the following standard(s): 3,6 Service users are adequately informed to make their choice of home. Their needs are met. EVIDENCE: Staff and service users were interviewed, and care practices were observed as part of the inspection process. Thorough assessments were recorded, and the inspector found no evidence to suggest that the service users needs are not met. A previous requirement had been met. Brackley Cottage Hospital provides intermediate care to up to 9 service users at any one time. These beds are contracted by the local Primary Care Trust. Service users receiving intermediate care were happy with the care which they received, and are given all of the support required to integrate them back into the community. One service user went on a home visit during the inspection. This group of service users had care plans specific to their rehabilitation needs. Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10 Service users needs are met, although thorough documentation was not available to instruct staff who are not so familiar with their needs. EVIDENCE: The care plans for the service user receiving intermediate care had plans pertaining only to the areas of need relating to their rehabilitation, meaning that one service user who had other medical conditions did not have care plans written in relation to these. The service user in a long term bed who was case tracked had all of their needs identified in the form of care plans. The content of the care plans was not adequate. Whilst they clearly identified the problem, and the goal, there were no instructions as to how staff were to meet the goal. The staff on duty demonstrated that they knew the service users extremely well, however clear instructions should be contained in a plan of care. There was no evidence that the service users were involved in the writing of their care plans. A previous requirement in relation to care plans had been met.
Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 10 Each service users file contained the appropriate healthcare assessments. Two previous requirements in relation to healthcare had been met. A sample of medication and associated records were viewed. These were all maintained to a high standard. A previous requirement and recommendation in relation to medication had been met. All of the service users spoken to, including those residing in shared rooms, stated that their privacy and dignity is maintained. Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14,15 Service users social needs are not adequately met, and sufficient records are not held. Service users are not offered choices in relation to food. EVIDENCE: There were no activities at the time of the inspection, despite the programme stating that bingo would be played. Some of the service users spoken to stated that they do feel bored at times. Records indicated that three service users regularly partake in activities, however there were no entries to demonstrate that activities had been offered to the other service users. The previous requirement remains outstanding. Service users stated that their visitors are welcomed into the hospital. A church service is regularly held on the premises. All of the service users spoken to stated that they are not offered a choice of meal. Records in the kitchen indicated that a choice was available, however this choice appeared not to be extended to the service users. This should be reintroduced. Choices in other areas of their care, i.e. when to bath, rise or retire were respected.
Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 12 Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Complaints handling is acceptable, and service users are protected. EVIDENCE: The hospital have not received any complaints since the last inspection. The complaints policy was satisfactory, and staff were aware of it. The hospital have a copy of the interagency protection of vulnerable adults policy. Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The premises are currently acceptable as fit for purpose, although space is limited. EVIDENCE: A tour of the premises was undertaken. Several service users reside in shared rooms, two of which have several beds in them. These rooms do not meet the national minimum standards. Service users spoken to all stated that they are happy with their rooms, which were noted to be personalised. Two service users occupying a shared room spoke very positively about sharing with each other. All areas of the home were clean and tidy. Radiator covers have been installed since the last inspection. The kitchen was well organised and managed. The inspector was advised that all of the equipment in the home was working. Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Staffing and training is satisfactory. EVIDENCE: The staff rota was viewed. The hospital have one nurse plus three auxiliaries on an early shift, and a nurse and a carer on a late and night shift. The nurse is also responsible for covering the treatment room which is attached to the hospital. Staff and service users spoken to stated that they felt that staffing levels were sufficient. Service users said that their call bells are answered promptly. A previous requirement in relation to the staff rota, and a recommendation in relation to supervision had been met. A sample of staff files were inspected. Recruitment of paid staff was satisfactory, however the documentation pertaining to volunteer staff was limited. The inspector was advised that voluntary staff who have applied recently have followed a more thorough recruitment process. It is recommended that this is maintained for future volunteers. The files also demonstrated that statutory training was up to date, and staff spoken to reinforced this. Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The home is managed to an appropriate standard. EVIDENCE: The home is managed to an acceptable standard. The manager is appropriately qualified. The inspector was advised that the hospital do not hold any money for service users, and it is the responsibility of the relatives to ensure that the service users have money available. Quality monitoring is undertaken, and the recent results contained generally positive feedback. There was evidence that adverse comments made are addressed. Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 17 Fire records were maintained up to date, and Portable Appliance testing had been completed timely. Accident records were satisfactorily held. Food was stored appropriately. Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 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 3 X 3 X 3 X X 3 Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 19 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 OP12 Regulation 16 Requirement Service users social needs must be met by the provision of regular, planned and meaningful activities. Records must be held of activities offered to or undertaken by service users. This requirement was made previously with a timescale of 15.2.06, which remains unmet. Timescale for action 10/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP14 OP29 Good Practice Recommendations Care plans should give specific instruction to staff as to how the service users needs must be met, and demonstrate the service users involvement in their writing. Service users should be offered choices at mealtimes. Recruitment of voluntary staff should be more robust. Brackley Cottage Hospital DS0000012602.V292915.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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