Inspection on 16/05/05 for Brantwood Hall Care Complex

This inspection was carried out on 16th May 2005.

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

Brantwood Hall Care Complex 05/01/07

Brantwood Hall Care Complex 13/01/05

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Whiteley House

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Beeches The - North Yorkshire County Council

The Grove Waltham

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

CARE HOMES FOR OLDER PEOPLE Brantwood Hall Complex 10-14 North Avenue Wakefield West Yorkshire WF1 3RX Lead Inspector Susan Vardaxi Announced 16 & 18 May 2005 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 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. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Brantwood Hall Complex Address 10-14 North Avenue, Wakefield, WF1 3RX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01924 364718 01924 386345 Winnie Care Mrs Dawn Wood Care Home 60 Category(ies) of Mental Disorder 60 registration, with number Physical Disability 60 of places Over 65 60 Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 14/12/04 Brief Description of the Service: Brantwood Hall Care Complex is owned by Winnie Care and is situated in North Avenue, Wakefield close to the town centre with good access to local transport. The local hospitals are close by. Brantwood Hall comprises of two buildings located in the same grounds which provide accomodation over three floors for 60 older people over the age of 65. Shaft lifts are provided in both buildings. The home is well maintained throughout with an active programme of refurbishment and good communal space. There are pleasant gardens to the rear of the building, which is accessible for the service users. Car Parking space is provided at the front. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Brantwood Hall Care Complex is under new ownership since the last inspection. Both buildings within the complex, previously registered as two separate care homes are now registered as one registered care home under the ownership of Winnie Care (Brantwood) Limited. This report is the result of an inspection over a period of two days of the provision of care and service provided in both establishments. There is now only one registered manager Dawn Wood who has overall responsibility for the management of both establishments; she is based in number 12-14 Brantwood Hall. Her deputy Angela Riley who oversees the provision of care and service at number 10-12 Brantwood Hall supports her. A partial tour of the building took place and staff and care records were inspected. Thirty residents and three visitors were spoken with and the interaction between staff and residents was observed throughout the inspection. Some requirements made at previous inspections remain outstanding and action must taken to comply with them. What the service does well: What has improved since the last inspection? There has been some carpet replacement, which was recommended at the last inspection. A mobile hoist has been provided which can be used in most areas at 10-12 Brantwood Hall and the laundry room has been fitted with a window which has improved the previous ventilation problems. An improvement has been made in the recording and administering of medications at number 12-14 Brantwood Hall. However further development is required to ensure that it is administered safely at 10-12 Brantwood Hall. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 6 The manager said that arrangements have been made to remove a sluice facility from a communal toilet. Service users have been given necklets so they are now able to use the emergency call system when sitting in the communal areas and the new lettering on the bedroom doors will help them to easily identify their rooms. 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. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 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 standard(s) 1,3 The arrangements for ensuring that service users needs can be met and that they are informed of the services to be provided on admission are satisfactory EVIDENCE: The statement of purpose and service users guide had been reviewed at the time that the home was registered under the new ownership. Two service users spoken with said that they had been given the home’s brochure on their admission to the home. Service user records show that pre admission assessments had been completed and letters had been sent to the service users confirming that the home could meet their needs. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 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 standard(s) 7,8,9,10 The care plans do not give clear guidance to staff. Risk assessments and further development of the recording and administering of medication is needed to ensure that service users are safe. The arrangements for Health care professional input are appropriate. Greater attention needs to be paid to the way staff appropriately support service users with their personal hygiene, and decisions about the support offered should be based on sound health professional advice and input. Service users are treated respectfully. EVIDENCE: Although care plans are reviewed monthly some information regarding the identified needs had been lost during the review process. A service user at risk from pressure sores did not have an appropriate care plan. The service user had signed only one care plan. The manager said that the home does not have an intimate care policy, despite the fact that there is a service user at the home who requires intimate staff assistance due to continence difficulties. Discussions with the service users found that GPs, district nurses, community psychiatric nurses and occupational therapists visit when required. These visits are recorded. The records showed that some service users had lost weight, with daily records entries referring to small or large diet taken. There was no evidence within the service user records to show that nutritional assessments Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 10 had been completed. On the whole, service users looked well groomed. However, the fingernails of one service user needed cleaning. The fingernails of one service user were seen to be very long, and the explanation given by the manager was that staff were reluctant to cut them due to the service user having diabetes. This person’s file did not contain any information or medical advice about nail cutting and diabetes. Service user risk assessments were seen to be on file, however risk assessments had not been completed for service users who are at risk from falling out of bed. The medication records at 10-12 Brantwood Hall had discrepancies. However no discrepancies were found at 12-14 Brantwood Hall. Service users said that their privacy and dignity are respected. This was supported with comments made within questionnaires received by CSCI and observations made while at the home. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13, 14,15 The provision of activities, outings and meals are satisfactory. EVIDENCE: Completed questionnaires and discussions with service users found that their views on the provision of activities and outings vary. Some considered the provision to be adequate, others said that there was not enough to do. Service users’ social needs are included in the care plans. Visitors said they can visit the home at any time, some service users said that service users from both buildings meet together for bingo which they enjoy. Service users said that entertainers visit regularly. A service user’s visitor said that their relative gets up too early, as she cannot see the clock. The meal sampled at lunchtime was cooked and presented to a good standard and provided a nutritious meal. The portions served were adequate and there was very little wastage. Special dietary needs were met and staff were seen offering choices and assisted residents appropriately. The service users spoken with said that the meals are good. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, Complaints are handled objectively EVIDENCE: The complaints records contained two complaints that had been made since the last inspection. These had been dealt with appropriately. Discussions with service users found that generally they are satisfied that complaints would be dealt with. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,23,24,26 The general standard of cleanliness and decor within the home provides a comfortable environment for residents to live in. The external environment is pleasant and accessible. Risk assessments must be completed for the type of beds currently in use to ensure that service users are safe at night. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 14 EVIDENCE: The home was seen to be decorated, maintained and cleaned to a good standard, the grounds were tidy and easily accessible. The communal areas provide pleasant environments for service users to sit and relax and eat in and it was noted that service users have access to the emergency call system as required at the last inspection. The bedrooms seen were clean and tidy and well decorated, a service user’s headboard was stained. The manager said a mobile hoist has been provided for use in number 10-12 Brantwood Hall to enable staff to assist service users who have disabilities, which had previously been difficult as the hallways are narrow. The manager said that the home has not considered using bed rails on the divan beds in service users’ bedrooms, as she does not consider this type of bed to be suitable for this purpose. The type of lettering used to identify bedrooms has been replaced so that service users with diminished eyesight can identify their rooms. The laundry facilities were checked and found to be clean and tidy and the provision of washing machines and tumble dryers are satisfactory. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Staffing levels are considered to be adequate during the waking hours. Staffing arrangements at night must be monitored regularly to ensure service users are safe at night. The homes procedures for obtaining information, POVA and CRB checks when recruiting staff do not ensure that residents are fully protected. The provision of staff training is adequate. EVIDENCE: The day staff spoken with said that there are enough staff on duty to meet service users’ needs appropriately and staffing levels are only affected when staff phone in sick. Rosters checked found that generally four carers are on duty during the waking hours. The manager said care staff are not involved in domestic duties and she and her deputy provided personal care if staffing levels are depleted. The records of the monthly accident audits seen identified that most accidents occur at night. This was discussed with the manager who said that she does not consider that this is due to staffing level arrangements at night. Staff files seen found that CRB and POVA first checks had not been completed prior to some staff being recruited. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 16 Staff spoken with said that they had had an induction and had been supervised throughout the induction period. The manager said that she has developed a new staff induction programme. Staff spoken with said that there were plenty of training opportunities for them. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36 38 The management arrangements are satisfactory and service users and staff are given the opportunity to voice their views on the service provided. Health and safety checks of the environment are needed regularly to ensure that service users are not at risk. EVIDENCE: The registered manager has a management qualification and management experience in a care setting. The deputy and area manager support her. Staff spoken with and records seen found that resident and staff meetings are held regularly. The manager said that she is re developing the quality assurance programme and staff have been given copies of the General Social Care Councils Code of Practice. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 18 Records of staff supervision were seen on the files checked and all records were seen to be stored securely. It was observed that a bedroom door did not fit securely into the jamb another bedroom door did not have a door closure fitted and a door wedge was seen in a bedroom. A build up of dust was seen behind the tumble dryers. A tablet of soap was seen in a shower room and disposable hand towels were not provided. Toiletries were seen on display on a hand basin in a service user’s bedroom. A mat was seen place on top of a fitted carpet, which could cause a risk from falling. Information provided on the pre inspection questionnaire demonstrated that fire system checks are completed and fire training is provided. Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 x x 2 3 x 3 STAFFING Standard No Score 27 1 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 3 x x 3 x 1 Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 20 YES 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 OP7 Regulation 15(2) 13 (4)(b)(c) Requirement Care plans must include all assessed needs. Risk assessments must be completed particularly when service users are at risk from falling out of bed. Nutritional assessments must be completed and records kept. Previous timescale of 31 January 2005 not met. The registered person shall make arrangements for the recording, safe adminsitration and disposal of medications received into the home. Previous timescales of 14th July and 9th February 2005 not fully met. Staffing levels at night must be kept under review to ensure service users are safe. The recruitment and selection process must ensure the fitness of staff is assessed against Regulation 4 (c) paragraph 2&3. Staff must not commence employment until satisfactory CRB and POVA checks have been completed, if this is obtained staff may, within Department of Health guidance, work under supervision pending CRB reply to Timescale for action 18 May 2005 2. OP8 17(1)(c ) 18 May 2005 & ongoing 18th May 2005 3. OP9 13(2) 4. 5. OP27 OP29 18(1)(a) 19(4)(c ) 18th May 2005 18th May 2005 & onoging Brantwood Hall Complex J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 21 6. OP38 13 4(a) (c ) 13(3) 23 4(a)(i) clearance requested. Previous timescales of 14th July 2004 and 9th February 2005 not met. The dates on a staff application form must be checked with the previous employers to establish the correct dates that the applicant was employed in their service. Risk assessments must be completed and appropriate action taken when service users choose to have mats placed on top of the fitted carpets in their bedrooms. Tablets of soap must not be left in communal toilets/bathrooms and disposable towels must be provided. A bedroom door that is difficult to push open and the bedroom door which does not close securely into the door jamb when must comply with fire regulations. Previous timescale of 14th december 2004 not met. Where service users choose to have their bedroom doors left open the fire service must be contacted for advice on an aprropriate device that could be fitted to enable the door to kept open however would close in the event of a fire occurring. It should be confirmed with the fire service if the door closing device on an identified bedroom door can be removed. 18th May 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations J51J01_s62445_brantwood hall complex_v219168_160505.doc Version 1.30 Page 22 Brantwood Hall Complex 1. OP7 2. 3. 4. 5. OP8 OP14 OP23 None Service users or their respresentatives should sign the care plans. Daily records should reflect more fully what action has been taken by staff to meet identified needs. An intimate care policy should be developed. Service users finger nails should be checked and cleaned daily. Staff should establish the with a named service user their preferred time to get up in the morning and if they want staff to call them so that they are not getting up too early. The heads board which is stained should be replaced. 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