Inspection on 10/12/07 for Bransfield Manor Rest Home

This inspection was carried out on 10th December 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

Bransfield Manor Rest Home 21/03/07

Bransfield Manor Rest Home 15/06/06

Bransfield Manor Rest Home 07/11/05

Bransfield Manor Rest Home 05/05/05

Bransfield Manor Rest Home 13/09/04

Bransfield Manor Rest Home 13/05/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Bransfield Manor Rest Home Bransfield Manor Church Lane Godstone Surrey RH9 8BW Lead Inspector Mary Williamson Unannounced Inspection 14th December 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 Bransfield Manor Rest Home DS0000042991.V357139.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. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bransfield Manor Rest Home Address Bransfield Manor Church Lane Godstone Surrey RH9 8BW 01883 742927 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) Family Care Private Company Limited Wanni Aylward Care Home 17 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (17), Sensory Impairment over 65 years of age (1) 357139 Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The combined total of residents falling into the category DE(E) and/or MD(E) must not exceed six (6) 21st March 2007 Date of last inspection Brief Description of the Service: Bransfield Manor is a care home registered for provision of personal care for older people from the age of 65 years. The home has a combined total of six places for the care of older people with either a diagnosed dementia or mental disorder, excluding learning disability. Additionally within the total numbers one placement may include an older person with a sensory impairment. The building is a large, detached Victorian property, situated in a semi -rural location, off a quiet country lane. The home is a short distance by car to Godstone village and accessible to larger shopping facilities in nearby towns. Bedroom accommodation is on three floors accessible by chairlift. Bedrooms on the second floor are only suitable for fully ambulant service users however. Communal lounge and dining facilities are available on the ground floor and assisted bathing facilities. Though the home has extensive gardens, the undulating, large rear garden is not suitable for use by service users. In fine weather service users enjoy sitting in a pleasant designated courtyard area to the side of the home or by the front door overlooking the car park. The fees at the home range from £398 pounds to £475 pounds per week. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of a key inspection and was unannounced. Mary Williamson Regulation Inspector carried out the inspection over four and a half hours. The Registered Manager Ms Wanni Aylward represented the home for the duration of the inspection. Discussions were held with the manager, residents, staff, and the registered provider. Records relating to the care of the residents and the management of the home were sampled. These included needs assessments, care plans, medication records, staff employment records, risk assessments, and health and safety procedures. Diverse needs of residents are recorded in individual care plans. It was possible to talk with residents and staff and gain feedback about their experiences of living and working in the home. The kitchen was visited and the cook spoken to. Menus were seen and lunch was observed being served. The manager completed an AQAA (Annual Quality Assurance Assessment) prior to the inspection. There is a complaints procedure in place and there have been no complaints recorded since the last inspection. The Commission for Social Care Inspection would like to thank the residents, and staff for their help and hospitality during the inspection process. What the service does well: The home offers a comfortable and homely environment with a relaxed atmosphere. Residents are supported with all aspects of care and daily life. Staff are understanding of residents needs and undertake their duties in a caring and confident manner. There are appropriate arrangements in place for health care needs and medication practice within the home is safe. The training and development of staff is ongoing and records indicated a commitment to this. Staff receive regular supervision. The health safety and welfare of staff is promoted and risk assessments are in place for identified risks and safe working practice. The home is well managed in the best interests of residents. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Bransfield Manor Rest Home DS0000042991.V357139.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 Bransfield Manor Rest Home DS0000042991.V357139.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are only admitted to the home following an assessment of their needs. The home does not provide intermediate care. EVIDENCE: The manager discussed the admission procedure. All the residents admitted to the home have a needs assessment undertaken prior to admission. This is undertaken by the manager to determine if the home is able to meet individual needs and the suitability of the prospective resident within the home. Assessments are either carried out in individual’s own homes or in hospital. Three needs assessments were randomly sampled. These are detailed and include all the relevant information for example medical reports and information provided by the relatives in order to make a decision regarding the placement. The home does not provide intermediate care. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans outline the care provided. Residents are treated with dignity and respect. The medication policy in place protects the residents living there. EVIDENCE: Individual care plans are in place. Three care plans were randomly sampled and are well maintained. Care plans are written based on information gathered from the needs assessment, input from the resident whenever possible, and information obtained from family and other health care professionals. These care plans are reviewed regularly and updated when required. The arrangements in place to meet the health care needs of the residents are satisfactory. All the residents are registered with a choice of local GP in three individual surgeries. Residents may retain their own GP following admission with mutual agreement. There are domiciliary visits from the chiropodist, dentist and optician. Specialist input for example psychiatry can be arranged via the GP. The Community Psychiatric Nurse (CPN) visits the home regularly to administer prescribed injections. Two residents commented that “they liked their doctor”. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 10 The home has medication policy in place and all staff who administer medication are familiar with this policy. Boots the Chemist at Oxted supplies the medication in blister pack format. They also undertake audits of medication. The medication recording charts (MAR) were seen and are well maintained. It was suggested to the manager that the inclusion of a photograph of each resident on the MAR charts for identification purpose could enhance safe practice. Allergies to medication are recorded. All staff had undertaken training in “safe handling of medication” in November 2007. Currently there are no residents in the home that self medicate. Residents are treated with dignity and respect. Staff were observed to interact with residents in a caring and professional manner. Staff always spoke to residents prior to undertaking a task. Staff were seen to knock on residents doors prior to entering. Keys are available to all residents if they choose to have one. Locks are provided on toilet and bathroom doors, and screens are provided in shared rooms. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity programme provided individual and group activities. Family links are maintained, and residents are supported to make choices. The nutritional needs of the residents are being met. EVIDENCE: There is an activities programme in place, which is displayed in the home. Activities include art and craft, scrabble, armchair exercise, music and movement, bingo, crossword puzzles, and reminiscence. The home also provides newspapers and the staff support residents to look at these and read articles to them. An art and craft class had taken place the previous day and the lounge was nicely decorated with Christmas decorations made at that class. Special occasions are celebrated for example birthdays, and the Christmas party had taken place the previous Sunday. Photographs of this were displayed in the lounge. Family links are maintained and visitors are welcome in the home at any reasonable time. Relatives are also included in the care planning process and are invited to attend reviews of care. Spiritual needs of residents are supported and the manager stated that two residents attend church. Arrangements are in place for various clergy to visit the home on request. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 12 The kitchen was visited and was clean and orderly. The cook plans the menus with input from the residents and an understanding of their requirements. The menus are varied and offer an alternative choice to residents when they don’ like what is offered. Lunch was observed and residents were enjoying fish and chips in pleasant and unhurried surroundings. Residents commented that “the food was good” and “ the roast dinners are excellent”. Staff were observed offering help and support to residents who required help with feeding. Special diets are catered including cultural needs. Snacks and drinks are available throughout the day. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 13 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, and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are protected by the complaints procedure and the abuse awareness procedure in the home. EVIDENCE: The home has a complaints procedure in place and all residents and their relatives have access to a copy of this procedure. There have been no complaints since the last inspection. The complaints log was seen and the last entry was made in 2004. Staff are also aware of this policy. Residents stated that they would complain to the manager if they had to. There is an abuse awareness procedure in place and this forms part of the homes induction training programme. Staff spoken to were aware of this policy and stated that they would not hesitate to make a referral if required to do so. There is also a copy of Surreys Multi-Agency Policies and Procedures on Safeguarding Vulnerable Adults and the manager has attended training in these policies. This has also been cascaded throughout the staff team. No referrals have been made under the local multi agency Safeguarding Adults procedures. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 14 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, and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is suitable for its stated purpose and is clean and hygienic. Parts of the home are in need of repair. EVIDENCE: Residents live in a comfortable and homely environment. The communal areas of the home provide ample space for the residents to relax and watch television if they wish. There is a second lounge without a television if preferred. During a tour of the building loose floorboards were noted outside room’s 1A and room 1B. The radiator cover in room 3 needed to be repaired. The home is an old property with high maintenance needs. It was particularly noted that the old window frames were in a bad state of repair, and needed to be repainted, and the sash cords replaced. The standard of cleanliness and hygiene is good. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 15 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, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by a team of staff with the appropriate skills and training. The recruitment procedure protects the residents in the home. EVIDENCE: The staff duty rotas were seen and evidenced that staff are employed in sufficient numbers to meet the assessed needs of the residents. The staff spoken to had a good understanding of the resident’s needs, and their care plans. They also had a good understanding of their roles and responsibilities. There is a well-established staff team in place with a low turnover. The home has a recruitment procedure in place. This is robust and protects the residents living in the home. Three staff files were sampled. These are well maintained and included all the required documents required for employment legislation, including two written references, an employment history, and a CRB (Criminal Records Bureau) disclosure number. Discussion with staff indicated the homes commitment to training and development. Staff are competent when undertaking their duties and professional in their manner. All staff undertake induction training and work with a senior member of staff until assessed as competent. Mandatory training is updated annually and includes manual handling, first aid, food hygiene, equality and diversity, risk assessment, safe handling of medication, and dementia awareness. NVQ is ongoing and staff are undertaking this award at various levels. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 16 All staff have contracts of employment and job descriptions. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 17 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, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed in the best interests of the residents. Financial interests are safeguarded and the health, safety, and welfare of residents and staff are promoted. EVIDENCE: The home is well managed by an experienced manager with a good understanding of the needs of the residents in her care. She also has obtained her Registered Managers Award (RMA). Her role is a “hands on approach” and she operates an open and inclusive style of management. She benefits from a senior staff team with the skills to take charge of the home in her absence. Formal staff supervision is in place and recorded. Quality assurance is monitored by regulation 26 visits by the provider. These are retained in the home for inspection. Regular reviews of care take place and health and safety audits are undertaken. Resident questionnaires are also sent and feedback acted upon. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 18 The home has a financial procedure in place. The home staff do not act as appointee for residents. Relatives are invoiced monthly for fees, which may also include hairdressing and chiropody costs. There are a wide range of health and safety policies and procedures in place, and some of these were sampled throughout the inspection. All staff receive induction training in health and safety procedures and this is updated frequently. COSHH procedures are followed and staff are aware of keeping chemicals locked. Risk assessments are in place for identified risks and safe working practice. Fire safety is observed and all staff have fire safety training yearly. The fire alarms are tested weekly and recorded. There is a contract in place for the maintenance of the fire fighting equipment and emergency lighting. Accidents are recorded in an appropriate manner and acted on accordingly. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 19 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 2 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 X X 3 Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23(2)(b) Requirement The registered person must ensure that all parts of the care home are kept in a good state of repair. The loose floorboards outside rooms, 1A and 1B must be repaired to prevent trip hazards. The windows throughout the home must have their sash cords repaired and wooden frames repainted or in some cases replaced. Timescale for action 20/01/08 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 OP9 Good Practice Recommendations Following a discussion with the manager it was recommended that a photograph of individual residents should be placed on the front of each medication recording chart for identification purpose and promote safety in medication administration. Bransfield Manor Rest Home DS0000042991.V357139.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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. 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