Inspection on 04/01/06 for Bramshall`s Old Rectory

This inspection was carried out on 4th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Bramshall`s Old Rectory 13/06/08

Bramshall`s Old Rectory 30/07/07

Bramshall`s Old Rectory 02/11/06

Bramshall`s Old Rectory 08/08/05

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bramshall`s Old Rectory Leigh Lane Bramshall Nr Uttoxeter Staffordshire ST15 5BQ Lead Inspector Lynne Gammon Unannounced Inspection 4th January 2006 09:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bramshall`s Old Rectory DS0000059275.V278382.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. Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bramshall`s Old Rectory Address Leigh Lane Bramshall Nr Uttoxeter Staffordshire ST15 5BQ 020 8423 8804 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) Tudor Care Plc Mrs Helen May Stanier Care Home 30 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (15), of places Physical disability (20), Physical disability over 65 years of age (25) Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD minimum age 60 Years Date of last inspection 8th August 2005 Brief Description of the Service: Bramshall Old Rectory is registered as a care home with nursing for 30 people, three of whom have dementia and are over 65 years of age, and old age with physical disability over 65 years of age. The home has 26 single and two double rooms for married couples or those who prefer to share. The home is situated in the village of Bramshall with good road access to Uttoxeter, some three miles away, in delightful country surroundings. The building is a converted church residence with modern extensions added over the years. The home is well suited to meet the needs of the stated categories of service users. Many rooms have impressive views of rolling countryside; all are well equipped and pleasantly furnished. Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was made on the 4th January 2006 at 9.45 am. The inspection was carried out by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. The total time spent for the inspection, including pre and fieldwork, amounted to 7 hours. The inspection included a part tour of the building, inspection of records, observation, and discussions with service users and staff. What the service does well: What has improved since the last inspection? A number of rooms had been redecorated and had new carpeting in place. The front lounge had also been redecorated and a new fire escape had been put in upstairs and three new nursing beds had been purchased. Abuse awareness training had also taken place for staff. Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 6 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. Bramshall`s Old Rectory DS0000059275.V278382.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 Bramshall`s Old Rectory DS0000059275.V278382.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): 2 and 4. Each service user had a contract with the home and they were assured that the home could meet their assessed needs before moving into the home. EVIDENCE: A service user’s contract was examined by the inspector and contained all required elements providing details of the terms and conditions of residency. The contract had been signed by a relative of the service user and dated accordingly. Relatives and/or the potential service user received confirmation that the home could meet the needs of the service user prior to moving into the home. Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8. The care planning processes were clear and detailed to enable staff to have a full understanding of service user’s needs. All health care needs were met and service users had access to a range of health professionals. EVIDENCE: Two service user care plans were inspected and found to be detailed and well organised to provide staff with information to understand and meet individual needs. Care plans were reviewed monthly and risk assessments were completed as required and also reviewed monthly. Health care needs were met very well and records showed that service users had access to other health care professionals. Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14. All key standards were inspected at the previous inspection on 08/08/05 and were met very well. A range of activities was available for the service users and they were enabled and supported to make their own decisions and choices about their own lives. EVIDENCE: The home had an activities co-ordinator who showed the inspector a selection of photographs of service users trying out a small, hand held harp during a visit from a harpist. A range of activities remained in place for the service users and discussions with them and observation throughout the inspection confirmed that they were supported and enabled to make their own choices and decisions about their day-to-day lives. Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 11 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): 17. Service user’s were enabled and supported to vote in elections and all key standards were examined at the last inspection and were met well. EVIDENCE: The Matron confirmed that each year registration forms were received from the Local Authority and were completed by staff for each service user to ensure that they could participate in the electoral process if they so wished. Since the last inspection no complaints or allegations of abuse had been received by the home or the Commission. Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23 and 25. Service users lived in safe, well-maintained surroundings, with adequate toilet and washing facilities and bedrooms suited their needs. EVIDENCE: The home was well maintained both externally and internally, and safe for the benefit of the service users. The Matron confirmed that a patio facility was being considered to improve accessibility to the rear garden for service users, particularly those who were wheelchair users. Toilets and bathrooms were satisfactory and very clean, and room dimensions and layout ensured flexibility of access for carers and any equipment required. The home was very clean throughout and service users lived in safe and comfortable surroundings where rooms contained covered radiators, smoke alarms and emergency lighting. A number of rooms had been redecorated and had new carpeting in place. The front lounge had also been redecorated and new furnishings were planned for it. A new fire escape had been put in upstairs and three new nursing beds had been purchased. Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27. All key standards were examined at the last inspection and were met well. EVIDENCE: The key standards were reported upon satisfactorily in the report of the previous inspection of 08/08/05, and the inspector identified no problems on this current occasion. Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 37 and 38. The registered care manager was fit to be in charge, responsible and of good character and service users were encouraged to provide feedback on service provision. Records held were accurate and secure. The health, safety and welfare of service users were upheld. EVIDENCE: The Matron was the registered care manager for the home and had worked at Bramshall’s Nursing Home since 2000 and as manager for over 4 years. She had qualified as a nurse in 1981 and was an experienced, professional manager who was very capable in managing her responsibilities and staff to meet the needs of the service users. The Matron provided the inspector with examples of how the home sought the views of service users to measure the success of the service. These included the cook asking the service users if they had any specific requirements over the Christmas period, comments requested from service users and relatives on Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 15 how the Resident’s Fund monies should be spent etc. Following discussions with the Matron and service users, the inspector was assured that on-going informal quality monitoring took place, but it is a recommendation of this report, that a more formal system is put in place to evidence continuous improvement in service provision with the involvement of service users and their representatives. Records for the protection of service users, individual records and home records were seen to be secure, up to date and in good order. The inspector examined a range of records and documentation, including the home’s policies and procedures, which had been reviewed in May 2005. Records evidenced that the health, safety and welfare of service users and staff were protected. Fire safety records showed a certificate of maintenance in June 05, emergency lighting and fire alarms were checked on 03/01/06. Other records included: hydraulic lift service on 18/11/05, gas safety inspection report on 10/01/05, a 10 year electrical installation inspection was undertaken in Jan 04, the Arjo Autolift was checked on 06/10/05, and a certificate dated April 05 provided evidence that the water tanks had been cleaned and disinfected. Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 16 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 X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 3 X 3 X 3 X 3 X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 3 3 Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 17 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 OP33 Good Practice Recommendations For a more formal system to be put in place to evidence continuous improvement in service provision with the involvement of service users and their representatives. Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Bramshall`s Old Rectory DS0000059275.V278382.R01.S.doc Version 5.1 Page 19 - 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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