Inspection on 15/02/06 for Braeside

This inspection was carried out on 15th February 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 but made no statutory requirements on the home.

Other inspections for this house

Braeside 30/08/07

Braeside 30/12/06

Braeside 10/08/05

Braeside 11/01/05

Braeside 30/11/04

Braeside 03/03/04

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 Braeside Stanhill Lane Oswaldtwistle Accrington Lancashire BB5 4QF Lead Inspector Mrs Lynn Mitton Unannounced Inspection 15th February 2006 10:00 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 Braeside DS0000009500.V281520.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. Braeside DS0000009500.V281520.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Braeside Address Stanhill Lane Oswaldtwistle Accrington Lancashire BB5 4QF 01254 398099 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) Mr George Anthony Hitchen Mrs Christine Philomena Hitchen Mrs Jennifer Mavis Brimlow Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Braeside DS0000009500.V281520.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2005 Brief Description of the Service: Braeside is a detached property situated on the main road in Oswaldtwistle within easy reach of local amenities. There was a parking area for visitors and staff. The accommodation provided for residents is mainly in single bedrooms, sixteen of which have an en-suite toilet and washbasin. There are three lounges and a dining room. The service is registered to provide personal care and accommodation to 24 people aged over 65 years. Braeside DS0000009500.V281520.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted approximately 6 hours. There were 23 residents accommodated at this time. A tour of the home took place. Over the course of the inspection three of the staff on duty, about 8 residents plus the registered provider and registered manager were spoken to, and interaction between the residents and staff members were observed. Throughout the report there are various references to the “tracking process”, this is a method whereby the inspector focuses on a small representative group of residents and care staff. Records pertaining to these people were inspected. Policies and practices were also read. The Commission had received no complaints since the last inspection. 4 service users relatives had completed the Commission’s comment card, and these indicated that they were very pleased with the level of service received at Braeside. What the service does well: One resident told the inspector “Its grand living here – home from home”. One residents’ relative commented; “ Braeside helped settle my mum in at a difficult time offering care and support at all times”. Anther relative commented; “My fathers entry into residential care has been wonderful for both of us. My father is happy, more confident, enjoys the company and the food is great. It gives me great peace of mind and I cannot praise the care at Braeside too highly, they are an excellent advert for residential care”. Residents were cared for in a way that promoted choice, dignity respect and fulfilment, and were given opportunities to exercise choice and control in their day to day living. The general layout and décor of the home provided comfortable surroundings, and was warm, tidy and clean. The attitude of the staff and management is to run the home around the needs and choices of the residents. Braeside DS0000009500.V281520.R01.S.doc Version 5.1 Page 6 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. Braeside DS0000009500.V281520.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 Braeside DS0000009500.V281520.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): OP2 & OP3 A contract was being completed and issued to each resident when they moved into the home. The admission procedure for new residents ensured that information about their care needs was obtained before they arrived. This enabled staff to have a clear understanding of what they needed to do for them. EVIDENCE: Contracts explaining the terms and conditions of residents stay at Braeside were completed for the two residents case tracked. The inspector saw two assessments of need which had been completed prior to new residents being admitted. Letters were being sent to residents advising them that Braeside was able to meet their needs. Braeside DS0000009500.V281520.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): OP7, OP8, & OP10 Care plans did not contain sufficient detail to ensure that all care and health needs were identified and interventions documented. Residents were cared for in a way that promoted choice, dignity respect and fulfilment. EVIDENCE: The inspector looked at two residents care plans. Some information was available identifying residents care and health needs and how these should be met. The inspector and registered manager discussed the information that should be included in each care plan. For example, they should contain a clear and concise identification of each persons needs and a description of how these needs are to be met by the care staff team. The content of and the use of language and phraseology in the assessment documentation and daily records were also discussed. Braeside DS0000009500.V281520.R01.S.doc Version 5.1 Page 10 Information regarding consent of administration of medication and a health needs risk assessment was forwarded to the registered manager. The inspector and registered manager discussed the practices of the district nurse observed at Braeside. From observations, the inspector felt that staff knew residents needs well, and they were treat with dignity, respect and autonomy. Braeside DS0000009500.V281520.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): OP12 & OP14 A regular programme of planned activities would ensure that residents had opportunities to engage in activities as well as having enjoyment, mental and physical stimulation. Residents were given opportunities to exercise choice and control in their day to day living. EVIDENCE: Records were kept of recreational activities undertaken. Bingo and manicures and foot spas took place on an ad hoc basis and craft activities took place fortnightly. Each week the hairdresser came to the home and entertainers also visited on an ad hoc basis. The inspector observed resident’s exercising choice and control over day-today elements of their lives. Care staff were seen to respect residents choices and opinions. Braeside DS0000009500.V281520.R01.S.doc Version 5.1 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 the following standard(s): OP16 & OP18 Further revision of Braeside’s protection from abuse policies and procedures would be of benefit in ensuring the safety of the residents, and give care staff clear guidelines. EVIDENCE: The complaints policies and practices documents had been updated since the previous inspection. There had been no complaints received since August 2005. The inspector noted there was a policy entitled “Protection of Vulnerable Adults” – this needed reviewing as it made reference to the NCSC. The registered manager and inspector also discussed the content of this policy and how easily care staff could understand it. The inspector advised that good practice would be to have a “policy of the month” as a means of raising care staff’s awareness of pertinent policies and practices. The inspector spoke to two staff member who had some understanding of what to do should they witnessed abuse of a resident, and were aware of whistle blowing. Braeside DS0000009500.V281520.R01.S.doc Version 5.1 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 the following standard(s): OP19 & OP26 The general layout and décor of the home provided comfortable surroundings, and was warm, tidy and clean. Odour management in some areas of the home needed further attention. EVIDENCE: Since the previous inspection, a keypad lock had been fitted on the laundry door, and resident’s toiletries were now kept in their own toiletry bag. There continued to be localised areas of odour detected in the home. The registered manager and inspector discussed how this was being managed. Cleaners were employed for 28 hours per week. The inspector noted that the TV Ariel in one lounge needed attention. The inspector and registered manager and registered person discussed plans for changing the layout of the home, making two bedrooms en-suite. Planning permission had been applied for. Braeside DS0000009500.V281520.R01.S.doc Version 5.1 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 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): OP28 & OP29 66 of care staff were trained to NVQ level 2 standard. Staff training ensures that the care staff team are able to competently care for the service users. Procedures for recruitment of staff and checks to safeguard residents must be in place. EVIDENCE: The inspector was advised that 8 out of 12 care staff had obtained either their NVQ 2 care qualification. The inspector was advised that a further 3 care staff were due to complete this training. The inspector observed residents being supported by competent and caring staff. One staff recruitment file was case tracked and was found to have shortfalls in the documentation required by legislation. The inspector advised that evidence of the prospective staff member’s good health must be sought prior to their employment at the home. The inspector and registered manager also discussed keeping evidence of staff training on care staff’s file, and ensuring that application forms are fully completed. Braeside DS0000009500.V281520.R01.S.doc Version 5.1 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 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): OP31, OP33, OP35 & OP38 The attitude of the staff and management is to run the home around the needs and choices of the residents. Residents and regular visitors to the home must be consulted about the dayto-day running of the home. The safety of some facilities at the home must be in place in order to ensure the safety of the residents and care staff team. EVIDENCE: The inspector was advised that the registered manager had completed the NVQ 4 and registered manager’s award qualification in 2002/2003. The registered person visits the home daily and his role includes ensuring the maintenance ad upkeep of the property. The registered person, registered manager and inspector discussed time management for the registered manager. Braeside DS0000009500.V281520.R01.S.doc Version 5.1 Page 16 A relatives survey had been developed and issued by the home. The inspector advised that this document should be dated and one for residents also implemented. These results should then be published and on display for residents and visitors to the home. The inspector was advised this would be done by April 2006. The registered manager was appointee for one resident, the inspector was advised that all other residents finances were dealt with by the residents themselves, their next of kin or families. On examination of the fire book, it was seen that the last fire test had been completed on 31/1/06. The registered manager was aware that this was overdue. The portable equipment test certificate had last been completed in September 2004, and as such was significantly overdue. Other safety certificates such as fire extinguisher and electrical installation certificate were in place and up to date. Bath water temperatures were checked and found to be 42 degrees centigrade. These checks must be regularly made and the results recorded. The inspector and registered manager discussed staff training to ensure that safe working practices are in place, for example moving and handling, and fire fighting training had been undertaken. Food Hygiene, Infection Control and 1st Aid however were outstanding for some care staff. Risk assessments were seen in place on residents care plans. Braeside DS0000009500.V281520.R01.S.doc Version 5.1 Page 17 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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Braeside DS0000009500.V281520.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 OP7OP8 Regulation 15 Schedule 3 Requirement The registered person must ensure the service users plan sets out in detail the action which needs to be taken by care staff to ensure all aspects of health, personal and social care needs of the service user are met. Information as identified in the Care Home Regulations must be kept for each person. The registered person must ensure that by staff training or other measures, to prevent residents from harm, abuse or being placed at risk or harm or abuse. Facilities at the home must be kept odour free and safe. The registered person must operate a thorough recruitment procedure at all times. The registered person must ensure that by staff training or other measures, to prevent residents from harm, abuse or being placed at risk or harm or abuse. Timescale for action 30/06/06 2. OP18 13(6) 30/06/06 3. 4. 5. OP19 OP29 OP38 23 (2) 19 13(6) 24/03/06 30/06/06 30/06/06 Braeside DS0000009500.V281520.R01.S.doc Version 5.1 Page 19 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. Refer to Standard OP12 OP33 Good Practice Recommendations Opportunities should be given for regular planned social and recreational activities. The registered person is recommended to ensure that effective quality assurance and quality-monitoring systems are in place to measure its effectiveness in meeting the aims and objectives of the home. Braeside DS0000009500.V281520.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Braeside DS0000009500.V281520.R01.S.doc Version 5.1 Page 21 - 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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