CARE HOMES FOR OLDER PEOPLE
North Yorkshire County Council Braeburn House Moor Lane Eastfield Scarborough YO11 3LW Lead Inspector
Pauline ORourke Unannounced 23 June 2005 9:30
rd 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. North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service North Yorkshire County Council Braeburn House Moor Lane Eastfield Scarborough North Yorkshire YO11 3LW 01723 582650 01723 586692 Address 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) North Yorkshire County Council Mrs Elizabeth Anne Stanley Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None. Date of last inspection 1st December 2004 Brief Description of the Service: Braeburn House is a care home providing personal care and accommodation for 40 older people. Five of the beds are used for short-term care..It is located approximately four miles from the centre of Scarborough. It is close to shops, the post office and other amenities. The home was opened in 1968 and consists of a three-storey building. The second floor is used as a separate day centre. The ground and first floor are used for the residential section of the building. All service users have their own bedroom. Two of the bedrooms can be used as double rooms if two people wish to share. There is a passenger lift. The home has grounds to the rear that are easily accessible. North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection including preparation time took place over 12 hours. A tour of the building was conducted. A number of the service users records, staff records and records about the management of the home were inspected. 12 of the 29 service users, and 4 of the 7 staff on duty were spoken with. What the service does well: 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.
North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 6 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 North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 7 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) None of these standards were inspected at this inspection. EVIDENCE: North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 8 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 and 9 The service users personal, social and health care needs are met. EVIDENCE: The service user files seen contained a Promotion of Independence Plan. This plan was pertinent to the individual concerned and there was clear evidence that staff review them every month. Service users spoken with had an awareness of their care plan and said that their key worker spoke with them on a regular basis about the help and support they need. The management team confirmed that staff conducted the monthly review without a reminder and they felt it was now a part of their regular duties. During the inspection the service users confirmed that they could see their GP on request. Evidence was also available to show that specialist support was sought when necessary to ensure that the health needs of the service users were being met. The administration and storage of medicines was seen to be appropriate and records kept were up to date and accurate. Several service users manage their own medication and facilities to ensure safe storage are provided. North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 9 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) 15 The service users have a varied and balanced diet. EVIDENCE: The service users spoken with expressed satisfaction at the quality and quantity of the food provided. They confirmed that there is a choice at each meal and that if they want something different to the menu it is provided. The meal observed was relaxed and the staff assisted service users appropriately where necessary. A four weekly menu was available for breakfast, lunch and tea. This was examined and appeared to provide a balanced and nutritious diet. The cook explained that local fresh produce is used and he was able to vary the menu to include seasonal foods. North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 10 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 Service users were confident that any complaints or concerns they had could be raised and acted upon EVIDENCE: North Yorkshire Social Services has a detailed complaints policy. This policy is provided to all the service users and is displayed around the home. There have been no complaints made to the CSCI or the home in the last 12 months. Service users spoken with all said that if they had any problems there was someone within the home they would go to. North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 11 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 and 26. The home was clean and benefits from a programme of works to ensure it is well maintained. EVIDENCE: The location and layout of the home is suitable for its stated purposes. Direct access to the grounds at the front and rear of the building enables service users who wish to sit outside. A patio area has been developed by staff for use by the service users. The service users spoken with said that they enjoyed using this area for outdoor activities. A security system ensures that staff know who is in the building at anytime. The home is in the process of being updated and this has included the outside being painted and a new lift being installed. All areas of the home seen were clean. North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 12 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) 28, 29 and 30. Service users are protected from possible abuse as the recruitment policy is fully implements and staff also receive regular training. EVIDENCE: Staff records showed that regular training is provided to ensure that staff have the skills needed to ensure the needs of the service users can be met. Of the 16 care staff employed only 3 do not have an National Vocational Qualification level 2. Staff spoken with said that they enjoyed the training provided and are currently undertaking a learning distance course on Dementia. Service users spoken with said that they felt the staff had the necessary skills to assist and support them. The staff files of three staff members were inspected. The files were seen to contain al the necessary documentation as required by the Care Homes Regulations 2001. Staff spoken with were clear as to their responsibilities within the home . North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 13 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, 35, and 38 The service users benefit from a competent manager who ensures that their financial interests are safeguarded. The health and safety of the service users and staff is promoted. EVIDENCE: The registered manager is qualified and is experienced in the care of older people. The service users financial interests are safeguarded. Staff handle the personal allowance for several service users and the appropriate records were accurate and up to date. The staff spoken with confirmed that they had received training in health and safety, first aid, back care, food hygiene, COSHH, and fire training. Evidence of this was seen in the staff files and the office diary.
North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 14 The equipment used in the building is serviced at the prescribed intervals. Accidents are properly recorded and where necessary reported to the Commission for Social Care Inspection. Information from the accident records is used in the care planning process. All staff have access to Induction and Foundation training. North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 15 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 4 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 x 3 x x x 3 x x 3 North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 16 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation None Requirement Timescale for action 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 None Good Practice Recommendations North Yorkshire County Council Braeburn House J53_J04_S34330_Braeburn House_V231992_230605_stage 4.doc Version 1.30 Page 17 Commission for Social Care Inspection Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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