Inspection on 30/08/07 for Braeside

This inspection was carried out on 30th August 2007.

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 30/12/06

Braeside 15/02/06

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 30th August 2007 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.V343144.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 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.V343144.R01.S.doc Version 5.2 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.V343144.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th December 2006 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 at the rear of the home. The service is registered to provide personal care and accommodation to 24 people aged over 65 years. There were 17 residents at the home at the time of the inspection. The accommodation provided for is mainly in single bedrooms, sixteen of which have an en-suite toilet and washbasin. There are three lounges and a dining room. Fees for the cost of a weeks care at Braeside ranges from £342.50 - £386.00. There was information available to potential service users and their families advising them of the home and giving them details about the type of service they could expect. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted on 30th August 2007. The registered person completed an Annual Quality Assurance Assessment. The inspector spoke to people in receipt of the service, visitors to the home and to the care staff on duty at the time of the inspection. Throughout the report there are references to the “case tracking process”, this is a method whereby the inspector focuses on a small representative group of people using the service. Records regarding these people were inspected. Two people were case tracked, their files examined in detail and two care staff member’s files were also case tracked. Information about the service was received on the Commissions resident’s questionnaire, and relative’s questionnaire. Comments and findings of these surveys are referred to throughout this report. The inspector conducted the inspection with the registered manager. During the inspection a number of records, policies and procedures were also viewed. What the service does well: One person using the service wrote; “ I like living here”. Another told the inspector; “I am very happy to be here, the food is very good and you get a choice if you want one. The girls are all very kind, all good and very obliging. I have no complaints and would talk to my daughter if I had any worries”. Contracts were issued to each resident when they moved into the home, ensuring that they were aware of the terms and conditions of their stay at 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. People using the service were treat with dignity and respect and were observed exercising choice and control over day-to-day elements of their lives. Visitors to residents at Braeside were made welcome. Meals were varied, enjoyed by all those spoken to and provided a social occasion on a daily basis. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 6 The general layout and décor of the home provided comfortable surroundings, and was warm, tidy and clean. The number of staff on duty reflected the needs of the residents. Resident’s finances were dealt with in a satisfactory manner. 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. The summary of this inspection report can be made available in other formats on request. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 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.V343144.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP1, OP2, OP3 & OP6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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: When asked if they received enough information about the home before they moved, one person wrote; “I was visited by the home in hospital”. Information about the home that would ensure potential new users of the service were well informed was dated 2003. The inspector advised that the residents guide should be in formats suitable for all potential residents, for example in large print. Two peoples files were examined during the case tracking process. Both had been issued with a contract; this document explained the terms and conditions Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 9 of their stay at Braeside, was dated and had been signed by the person using the service. One person needed a more up to date contract. Assessment documentation had been completed for both people prior to their admission. Assessment documentation contained sufficient information to develop a plan of care and meet the person’s needs. Intermediate Care is not offered at Braeside. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans did not contain sufficient detail to ensure that all care and health needs were identified and interventions documented. Medication stored and administered in a safe manner. Residents were cared for in a way that promoted choice, dignity respect and fulfilment. EVIDENCE: When asked what the care home did well, one health professional wrote; “Honest, helpful, very caring, keep records up to date, well organised by the manageress”. Two plans of care were examined and one contained some information care staff needed to look after each person. Information about people’s health needs, and how these should be met were also in place. One person’s care plan and health records had not been reviewed since August 2006. One care plan did not have a photograph of the person. The inspector Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 11 was advised that a new care plan format was being introduced. The inspector advised that all peoples care plan should be updated on the new format as soon as possible. Daily records contained relevant information. A new medication administration system had been introduced since the last inspection. This meant that the administration of people’s medication was now much safer. The home medication policies and procedure was dated March 2004. The inspector advised that the policies and procedures must be updated and that the visiting pharmacist should leave a copy of a record of their visit. Members of staff administering medication had undertaken training. The inspector noted that only one persons file case tracked had a administration of medication consent form completed. People using the service told the inspector that some felt they were spoken to and treat with dignity and respect and gave examples of this. The inspector also observed this was the case. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP12, OP13, OP14 & OP15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were given opportunities to exercise choice and control in their day to day living. Visitors to residents at Braeside were made welcome. Meals were varied and provided a social occasion on a daily basis. EVIDENCE: When asked what the care home did well, one resident’s family member wrote; “The care home always keep the residents clean, well cared for and well fed. They do their utmost to encourage the residents to eat and drink”. The inspector observed people exercising choice and control over day-to-day elements of their lives, for example, spending time in their room, and getting up at different times. Care staff were seen to respect these choices and opinions. A weekly activity planner was in place. This included activities such as nail art, beetle drive, dominoes, bingo, craft and foot spa. The inspector was advised that about 2 activities per week took place, and that a sweet shop was due to be introduced in the near future. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 13 Members of the clergy who regularly visited the home on a monthly basis met resident’s religious needs. One person goes out into the local community of their own accord. The inspector advised that a risk assessment should be in place. Resident’s bedrooms were seen furnished with personal belongings. A number of visitors came to the home on the day of the inspection, and were made welcome. The visitors’ book was not always being completed. It was noted that the day’s menu was not on display. Residents with special needs, for example diabetic and soft diets were catered for. Plate guards were seen to be in use. Nutritional assessments were not seen on care plans case tracked. The homes fridges were recorded as being between plus 12 and plus 14 degrees. This was discussed at the time of inspection. When asked if they liked the meals at the home, one person using the service wrote; “Excellent meals, I like Fridays best as its fish and chips”. Another person using the service wrote; “The food is very good”. One resident told the inspector told the inspector “They’re all good meals here, couldn’t ask for better”. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP16 & OP18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints were dealt with in a satisfactory manner. Current complaints and prevention of abuse policies and procedures do not ensure the safety of the residents, nor do they give care staff clear guidelines. EVIDENCE: When asked if they knew who to speak to if they were unhappy, one person using the service wrote; “I haven’t needed to speak with anyone as they are all good with me, but I know who to speak to if I had a problem”. There had been one complaint to the Commission since the previous inspection. The homes policies and procedures had not been recently updated and contained out of date information about the commission. There was not a system in place for recording complaints and demonstrating how they had been dealt with. The complaints procedure was on display outside the office. The inspector noted there was a Protection of Vulnerable Adults policy, which made included information about whistle blowing. However, this needed updating as it made reference to the NCSC. The inspector was advised that all care staff had not yet completed prevention of abuse training. The inspector advised that this matter should be given high priority. One member of staff spoken to was able to describe the different types of abuse and what she would do if she had any concerns. Most staff had completed Prevention of Abuse training. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 15 Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP19 & OP26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general layout and décor of the home provided comfortable and clean surroundings, and was warm, tidy, clean, and mostly free from offensive odours. Aids and adaptations met resident’s needs. EVIDENCE: The inspector conducted a tour of the building and visited all communal rooms and most bedrooms. The home was clean and homely. Two empty bedrooms were odorous, how to resolve this was discussed at the time of the inspection. The inspector was advised that carpets were cleaned monthly. The inspector was advised that a new oven had been installed, and the passenger lift had been refurbished. One bedroom had been converted to a smoking room for residents. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 17 An Evacuation chair had been bought for the first floor on the recommendation of the fire service. There was moving and handling equipment to meet resident’s needs. The laundry was seen and it contained equipment to sufficiently meet the needs of the people using the service. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP27, OP28, OP29 & OP30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number of staff on duty reflected the needs of the residents. Recruitment and selection procedures were not robust enough to fully protect residents. Training undertaken ensured care staff had the skills to care for residents. EVIDENCE: When asked if staff are available when you need them, one person wrote; “Someone is about most of the time”. The staffing rota was seen; this demonstrated that there were sufficient staff members on duty to care for the needs of people using the service. There were 2 care staff plus a senior member of staff on duty from 8 am until 5pm and 3 care staff from 5pm until 10 pm. Overnight there was 1 wake and watch and one sleep-in staff. There was a cook employed 35 hours per week and domestic staff. The registered person visited the home regularly, undertaking general maintenance of the home. Two staff files were case tracked these mostly demonstrated that staff were being recruited in a way that safeguarded people using the service. There was no evidence that one member of staff had a CRB check. One member of staff did not have a photograph on file. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 19 The inspector and registered manager discussed improvements that could be made to the recruitment process, for example, developing recruitment interview questions and recording the applicant’s responses. Training records showed that ten out of the thirteen care staff had obtained NVQ2/3, and three were undertaking this training. The most recently recruited member of staff case tracked had started the Common Induction Standards training. However this should have been completed within the first three months of employment, and this was not the case. The training matrix demonstrated that all staff had completed some training. The inspector advised that the matrix show the dates that the training was completed. Some training was outstanding, for example, all staff needed infection control and health and safety training. Records of a 1:1 meeting was seen for one person, however the inspector was advised that formal 1:1 supervisions did not take place and were not recorded. Instead informal chats took place on an as and when basis. The inspector advised that regular staff meetings, 1:1 supervisions and annual appraisals should be in place. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP31, OP33, OP35 & OP38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The attitude of the staff and management was to run the home around the needs and choices of the residents. Resident’s finances were dealt with in a satisfactory manner. Not all health and safety issues were being addressed; this may leave some residents and members of staff at risk. EVIDENCE: The registered person visits the home daily and his role includes ensuring the maintenance and upkeep of the property. The registered manager and inspector again discussed better time management and prioritising the homes paperwork. A relatives and residents survey had been undertaken between November 2006 and July 2007. The results had been collated and published. The Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 21 inspector was advised that the Investors in People Award was due for renewal in October 2007. The registered manager was not appointee for any resident; the inspector was advised that except for one person, personal financial affairs were dealt with by the residents themselves, their next of kin or families. The inspector noted that the fire system had been independently checked in August 2007. The last fire drill had been conducted in July 2007, and the last test on August 2007. Fire extinguishers were last tested in April 2008. The inspector advised that a safe way of keeping fire doors open in communal areas and one resident’s bedroom door must be sought or else they must be kept closed. The inspector saw on the training matrix that the care staff had received prevention of fire training, but the date was not recorded. There had been a Gas Safety check completed in May 2007. A portable appliance test had been completed in July 2007, and the 5-year electrical wiring certificate had been completed in September 2003. The homes lift had last been service in May 2007. The training matrix demonstrated that care staff had not received training regarding infection control or health and safety. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 22 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 X X X 2 Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 Schedule 3 Requirement Timescale for action 01/02/08 2. OP8 15 Schedule 3 3. Braeside OP9 13(2) 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. This requirement has been outstanding since 10th August 2005 The registered person must 01/02/08 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. This requirement has been outstanding since 10th August 2005 The registered person shall make 01/02/08 arrangements for the recording, DS0000009500.V343144.R01.S.doc Version 5.2 Page 24 4. OP15 16(2)(g) 5 6 OP16 OP18 22 & Schedule 4 (11) 13(6) 7 OP29 19 8 OP30 18(1)(c) handling, safe keeping, administration and disposal of medication. The homes fridges must store the food at between plus three and plus eight degrees to reduce the risk of contamination and food poisoning. This requirement has been outstanding since 15th Dec 2006. The complaint policies and practices must be in accordance with this legislation. 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. The registered person must operate a thorough recruitment procedure at all times. This requirement has been outstanding since 15th Feb 2006 The registered person shall ensure that persons employed at the care home shall receive training appropriate to the work they are to perform. 01/02/08 01/02/08 01/02/08 01/02/08 01/02/08 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 OP12 Good Practice Recommendations Opportunities should be given for regular planned social and recreational activities. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 25 2. 3. OP13 OP15 The visitor’s book should be completed at all times. The day’s menu should be displayed. Nutritional assessments should be on each persons care plan. Braeside DS0000009500.V343144.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Braeside DS0000009500.V343144.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!