Inspection on 07/02/07 for Braeside Care Home

This inspection was carried out on 7th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Braeside Care Home 05/02/09

Braeside Care Home 04/05/06

Braeside Care Home 10/01/06

Braeside Care Home 25/04/05

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 Care Home 8 Royal Street Smallbridge Rochdale Lancashire OL16 2PU Lead Inspector Bernard Tracey Unannounced Inspection 7th February 2007 09:30 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 Care Home DS0000063307.V298316.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 Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Braeside Care Home Address 8 Royal Street Smallbridge Rochdale Lancashire OL16 2PU 01706 526080 01706 860923 matron.braeside@yahoo.co.uk 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) East & West Healthcare Limited Christine Julie Baines Care Home 36 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (13), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (1), Old age, not falling within any other category (22), Physical disability (1) Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for a maximum of 36 service-users to include: Up to 13 service-users in the category of DE(E) (Dementia over 65 years of age); Up to 22 service-users in the category of OP (Older People) Up to 1 service-user in the category of DE (Dementia 55-65 years) Up to 1 named service user in the category of MD(E) (Mental disorder over 65 years of age) Up to 1 service user in the category PD (Physical Disability 60 - 65 Years old) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The service should at all times employ suitably qualified and experienced members of staff, in sufficient numbers to meet the assessed needs of the service user group, including at least 6 hours Registered Mental Nurse input each day. 4th May 2006 2. 3. Date of last inspection Brief Description of the Service: Braeside is a privately owned care home providing personal and social care, nursing and care for those with dementia. The home was formerly a domestic property, which has over the years, been extended to accommodate 36 residents. It is located on the main Halifax Road, approximately 1 mile from Rochdale and a regular bus service between Littleborough and Rochdale stops close to the home. Accommodation is provided on three floors in both single and double bedrooms. There is level access to the front door and a small garden/patio area is provided to the front of the home. There is no designated parking area but cars may be parked on the minor road. A copy of the most recent Commission for Social Care Inspection report is available in the reception area of the home. The home makes the following charges over and above the weekly care and accommodation fees that are listed after this section: Chiropody £10.00 Hairdressing £4.50 Men £6.00 - £19.00 Ladies Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 5 Fees charged by the home provided in February 2007 are as follows: £326.00 per week to £365.00per week Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The home was not made aware that this site visit was going to take place. Several weeks before the inspection questionnaires were sent out to doctors, social workers and district nurses, as well as to the residents of the home and their relatives. The questionnaires asked what people thought of the care and services provided by the home. The home was also asked to fill in a questionnaire. The Inspector spent 4.5 hours at the home. During this time we looked at care and medicine records to ensure that health and care needs were met and also studied how information was given to people before they decided to move into the home. A tour of the building was undertaken and time was spent looking at records regarding safety in the home. He also examined files that contained information about how the staff were recruited for their jobs, as well as records about staff training. We spent time speaking to 7 residents as well as speaking to 1 relative, 5 staff, and the manager. What the service does well: What has improved since the last inspection? A continuous programme of improvements and maintenance ensures that the accommodation is kept to safe and comfortable standards. Recent improvements have included re-decoration and refurbishment of some bedrooms. The home now ensures that residents are seen before coming to the home so that they are sure that their needs will be able to be met. The home involves residents and relatives in drawing up and reviewing the care plans. The care plans have been updated to include all of the residents’ health care needs and show how these are to be met Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 7 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 Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 8 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 Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 9 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): 3. Standard 6 does not apply Quality in this outcome area is good Admissions are not made to the home until a full needs assessment has been undertaken. The home are then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Before any resident was admitted to the home an assessment of their needs was undertaken, either by a senior member of the nursing staff from the home or from the professional i.e. Rapid Response Nurse requesting their admission. The assessment documents of three residents were looked at. The assessments were detailed and gave a clear indication of the residents’ needs and their capabilities. The assessments looked at the physical, mental and social care needs of the residents as well as the involvement if any, of their relatives. The Inspector spoke with the relatives of a resident who had recently been admitted, who stated that the manager had been out to the Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 10 residents’ home to undertake an assessment of her needs and also provided information that helped them to come to the decision that the home would be able to meet her needs. All of the questionnaires returned to the Commission confirmed that each individual felt that they had received enough detailed information prior to making a decision to come into the home. All residents spoken with stated that they had received a contract from the owner that describes the terms and conditions of their stay. Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 11 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): 7 8 9 10 Quality in this outcome area is good The care plans reflected the support needs of the residents. Care practices ensured that the residents health care needs were met, that they were treated with respect and that their dignity was upheld. The medication system in place ensured that the residents received their medicines safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents have an individual plan of care and we examined four files as part of the Inspection process (two files of residents on the dementia unit and two files of residents on the nursing unit). The care files are accessible for staff, they are organised and the information is detailed and easy to read. Care documentation seen had also been reviewed regularly to ensure it was accurate and reflected any change in care or treatment. Staff pay a great deal of attention to recording all aspects of care, for example, maintaining a safe environment, communication, personal care, food and nutrition, social needs and sleeping. Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 12 The resident’s right to privacy and dignity had also been incorporated in the care plans and there were good instructions for staff on how to deliver the care. The resident or their representative had signed the care plans examined and relatives interviewed were familiar with the care reviews. General risk assessments, including manual handling instruction, are in place for residents who are at risk of falling or who require assistance with their mobility. Risk assessments for, nutrition, care of resident’s skin and self medication had also been completed. There was evidence that a plan of care was in place where a risk had been identified. Residents who may have difficulties with their diet or weight loss are referred for specialist support. A record is kept of GP visits or external health appointments and a resident said, “I can see my doctor at any time and the chiropodist comes regularly”. Residential residents receive input from the District Nurses. The District Nurses maintain their own notes and advise staff of the treatments they are giving. There was evidence of their visits in a care file examined. Comments from residents regarding the care include: “Staff are excellent” “The care is really good” “Could not wish for better” “If I wish to see my doctor or my dentist or need a change of prescription this is dealt with very promptly” The medication system was safe. Medications were securely stored and were administered by the qualified nursing staff or senior care staff who had received the appropriate training. Staff were observed as being competent and caring in their attitude when providing personal care for residents and also having sufficient time to spend with them; they did not appear rushed in any way. Residents interviewed stated that staff were very respectful and also had a good understanding of how to care for older people. Comment cards received from relatives included: “It is a credit to the staff and a pleasure to visit. We feel our relative could not be better cared for. The family are pleased with the care.” “The staff always have time for her and her family and nothing is too much trouble” Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 13 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): 12 13 14 15 Quality in this outcome area is good Residents are able to exercise choice and control over their lives and are offered a choice of well balanced and nutritional meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The resident’s involvement in social activities varies greatly according to their abilities and nursing needs. Some of the residents spoken to preferred to stay in their own bedrooms and enjoyed reading, listening to music and watching the television. The choices residents made each day varied, dependent upon their mental frailty but residents generally chose what time to get up, go to bed, what clothes to wear, where to spend their day, what food to eat, whether to participate in activities. Overall, residents considered they were encouraged to do what they could for themselves and make appropriate choices through the day. The home gathers a social history, usually from the relatives, which is used to identify interests and hobbies previously undertaken by the resident. This Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 14 social history is used to help to provide the staff with details and to encourage the individual to participate in appropriate activities. The manager has recently placed an advertisement for the vacancy of activity co-ordinator and it is envisaged that when the post is filled further developments in the activity programme can be made. Residents told the Inspector that they are able to have visitors at any reasonable time and they can see their visitors in private. Two relatives told the Inspector that the staff at the home always made them very welcome. Records of food provided to residents confirmed that all receive a varied and nutritious diet. The residents were asked what they would like to eat and alternative meals are available. The food was served from a hot trolley that was brought through into the dining room. The tables were nicely set with tablecloths, napkins and cruets. Hot and cold drinks were served. The residents spoke positively of the food provided. Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 15 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): 16 18 Quality in this outcome area is good The home has a clear complaints procedure and residents and their families know action will be taken to resolve their concerns. Staff have a good knowledge and understanding of Adult Protection issues which safeguards residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaint procedure is on display and residents and relatives interviewed were satisfied with all arrangements in the home but were aware of how to make a complaint if needed. A staff member said, “If a resident wanted to make a complaint, I would go to the nurse in charge”. The complaint log was seen and no complaints have been received. One response from a relative stated:” We complained at the beginning of mum’s stay in Braeside. It was dealt with efficiently and has not occurred since.” The policies and procedures regarding protection of residents are satisfactory and are regularly reviewed and updated in line with regulations and other external guidance. The home had the latest guidance on the local multidisciplinary procedures for reporting abuse. Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 16 Staff have received Adult protection training and demonstrate an awareness of the content of the policy and know the immediate action to take, and who to refer to. Feedback from relatives and others associated with the home state that they are very satisfied with the service provision, feel very safe and well supported by the home which has the protection and safety of residents as a priority. Some care plans had instructions on how to handle people when they became agitated and aggressive. Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 17 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): 19 26 Quality in this outcome area is good The home has a planned maintenance and renewal programme for the redecoration and refurbishment of the home to ensure residents live in a comfortable, homely and safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is suitable to meet the needs of residents. Specialist equipment is provided including grab rails, a call bell system and assisted bathing and toilet facilities. The home is well laid out and accommodation is clearly signed so that residents can identify their own rooms. Recently nine bedrooms have been re-decorated. The manager has developed a maintenance programme for the home, which identifies areas for priority. The next improvement will be the hallways and replacement of curtains in this Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 18 area. There are some bedrooms which are in need of decoration, and these are included in the plan of improvements. A tour of the home confirmed that the home was well maintained, clean and free from any offensive odours. Ramped access was provided to the front door and level access throughout each of the three floors. A passenger lift was provided and handrails fitted to corridors throughout. Everyone spoken with thought the home was a safe place to live and work in. Residents said staff kept the building clean and odour free, inspection of the premises supported this view. Discussion with the domestic staff verified that sufficient staff and equipment were provided to ensure the home was maintained in a clean and hygienic condition. An infection control policy was in place and training was provided in this area. Staff spoken with described safe infection control practice. Satisfactory practice was in place with regard to disposal of clinical waste. The laundry was sited away from the food preparation area and was seen to be clean and orderly. Sufficient and suitable equipment was provided and laundry was attended to efficiently. Three residents said that they were satisfied with the laundry system at the home and that there was a quick turn around on the clothes sent for cleaning. Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 19 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): 27 28 29 30 Quality in this outcome area is good Staff are well trained to ensure they have the competencies to meet residents needs. The deployment of staff throughout the day is sufficient to meet the needs of residents. The homes recruitment procedures are robust and these provide safeguards for the protection of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector examined staff files and found that they contained all the information required, confirming that the recruitment procedures had been followed. The manager is in the process of re-organising all of the personnel files so that they are easier to read and information contained in them more accessible. A newly recruited Carer said she had been given an induction to the home and spoke about the content of the programme and the support she had received. The carer felt the induction process was well organized and thorough enabling her to get to know the residents in the home as well as becoming familiar with the way the home was run. The Inspector examined the rotas and found that the staffing levels were sufficient for the number of residents in the home and to meet their needs. Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 20 Training is high on the agenda and comprehensive records are kept of the training undertaken by staff. Staff spoken to informed the Inspector of the training that they had done, including care of residents with dementia. They stated that they are encouraged to attend courses and given the time and support to do this. The home has approximately 60 trained to at least NVQ Level 2 with 3 more staff working towards the qualification. Staff spoken to said that they were clear about their role and work well as a team to ensure the individual and collective needs of the residents are met. Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 21 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): 31 33 35 36 38 Quality in this outcome area is good The home is well managed and run in the best interests of residents This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a qualified nurse who has many years experience in caring for residents and is presently studying for a management qualification. Throughout the inspection the Inspector was able to observe the professional, capable and approachable manner in which the manager undertook her role when dealing with residents, staff and visitors. The home has good systems in place to gather staff, residents and relatives’ views as part of the monitoring of quality. Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 22 Staff spoken to had a clear understanding of their role and what was expected of them. The Inspector saw documentation that confirmed that staff received regular supervision and annual appraisal. Residents, relatives and staff spoke well of the management team and the care and support that they give. The Inspector was able to witness their approach to the residents and staff and confirm that comments made. Information provided by the manager and examination of the records, confirmed that all safety equipment is regularly serviced. The policies and procedures in the home ensure that the health, safety and welfare of the residents and staff are promoted and protected. Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 23 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 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 3 X 3 Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation 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 OP12 Good Practice Recommendations Staff should continue to develop activity provision throughout the home. Braeside Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Care Home DS0000063307.V298316.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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