Inspection on 05/01/07 for Brantwood Hall Care Complex

This inspection was carried out on 5th January 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 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 16/05/05

Brantwood Hall Care Complex 13/01/05

Similar services:

Snydale Care Home

Abbey The

Whiteley House

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Brantwood Hall Care Complex 10-14 North Avenue Wakefield WF1 3RX Lead Inspector Mrs Janis Robinson Unannounced Inspection 5th January 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 Brantwood Hall Care Complex DS0000062445.V315194.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. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brantwood Hall Care Complex Address 10-14 North Avenue Wakefield WF1 3RX 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) 01924 364718 01924 386345 Winnie Care (Brantwood Hall) Ltd Dawn Ann Wood Care Home 60 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (60), Old age, of places not falling within any other category (60), Physical disability over 65 years of age (60) Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can accommodate one named service user under 65 years of age Date of last inspection 16th May 2005 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. Brantwood Hall comprises of two buildings located in the same grounds, which provide accommodation for 60 older people over the age of 65. The home is well maintained throughout with an active programme of refurbishment. There are pleasant gardens to the rear of the building, which are accessible to service users. Car Parking space is available. Current fees range from £359 - £403 per week. Written information about the home is available to prospective and current residents and their representatives. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors, Janis Robinson and Rob Curr, undertook a site visit over 4.5 hours on the 5th January 2007. The inspectors spoke with the registered manager to gather information about the home. A proportion of the staff on duty were spoken with about aspects of their job and three members of staff were formally interviewed. A proportion of residents were spoken with about what it was like living at the home. Interactions between staff and residents were observed. A proportion of communal and individual living space was inspected. A selection of records was examined, including; pre-admission assessments, care plans, accident records, complaints and adult protection policy and procedures, staff training and recruitment, fire records and quality assurance. In addition to the site visit a pre-inspection questionnaire was undertaken by the manager. Surveys were sent to a proportion of residents, their relatives, and health professionals. Six residents and fourteen relatives completed and returned their questionnaires. The inspectors would like to thank the manager, residents and staff for their welcome and cooperation with the inspection process. What the service does well: All of the comments made by residents on the day of the site visit were positive. Residents and relatives said ‘staff couldn’t be kinder’, ‘I am very happy here’, ‘my wife is well cared for’, ‘the food is good’, and ‘nothing to too much trouble for the cooks’. The interactions observed between residents and staff appeared patient and caring. Staff displayed a commitment to their jobs. The manager appeared professional, well organised and caring in her role. Staff felt supported by the manager and her team. The majority of records inspected were well organised and up to date. Written policies and procedures were in place to ensure staff were well informed and residents were safe and well cared for. The environment was well maintained Brantwood Hall Care Complex DS0000062445.V315194.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. Brantwood Hall Care Complex DS0000062445.V315194.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 Brantwood Hall Care Complex DS0000062445.V315194.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): 1,3,4 and 5. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A written statement of purpose and service user guide was available to prospective and current residents and their representatives to give them information about all aspects of the home. Assessments were undertaken prior to admission to ensure all individual needs were identified and could be met. Prospective residents and their representatives were able to visit the home prior to admission to inform their choices. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 9 EVIDENCE: Each resident and their representative had been provided with a service user guide. This contained comprehensive information about all aspects of the home. It was well set out and easy to read. A statement of purpose was available and on display. Assessments were undertaken prior to admission for all prospective residents. The manager or owner visited prospective residents in their own home, or hospital to gather information. In addition, prospective residents were invited to spend the day at the home, meeting staff and residents, to assist the assessment process. Assessments were in place in the three residents files inspected. They included sufficient detail to ensure a comprehensive and individual plan of care was developed. The staff spoken with evidenced a commitment to caring for residents. They appeared knowledgeable about individual needs and how these could be met. All prospective residents and their representatives were able to visit the home before deciding to move in, the visit would involve meeting staff and residents, joining in any activities if desired, viewing the accommodation, and staying for meals. If needed, more than one visit to the home could take place to help prospective residents make a decision. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Each resident had a care plan, which identified his or her individual needs and preferences. Residents’ health care was monitored and access to health care professionals was available, to ensure health needs were met. Medication policies and procedures protected residents. Residents felt respected by staff at the home. EVIDENCE: Three care plans were inspected. Each was fully completed and up to date. Care plans had been reviewed on a monthly basis. The plans contained comprehensive information on individual needs and preferences. The plans Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 11 included details of the staff action required to ensure needs were met. Risk assessments had been undertaken. Health care was monitored. All contact with health care professionals was recorded. The residents spoken with confirmed that they met with their doctor, chiropodist, optician and dentist when required, and always saw these people in private. Residents said that staff looked after them well. The care plans inspected recorded regular weight checks, nutritional assessments, skin care and other information covering all aspects of health. Medication systems in the home were safe. The staff that administered medication confirmed that they had been provided with training. Medication was stored securely. The medication administration records inspected were fully completed and up to date. The medication records corresponded with the drugs held. The interactions observed between residents and staff appeared respectful and caring. Staff were seen to knock on doors and wait for a reply before entering rooms. All of the residents spoken with said that they felt respected by the staff at the home. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. An activities programme was provided to maintain residents’ interests and social opportunities. Contact with family and friends was supported to maintain relationships. Residents’ opinions were sought, to ensure they had a choice. A varied diet was provided to maintain health and give residents choices. EVIDENCE: All of the residents spoken with said that enough activities were provided. Two residents said in their surveys that they would like more outings. A record of all activities was kept. This evidenced that a choice was provided to residents. Photographs of recent events were on display throughout the home. Residents were free to join in activities, or not, as they wished. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 13 An open visiting policy was in operation. The manager and staff reported good relationships with relatives. One relative said ‘my wife is well cared for’. All of the residents spoken with said that their friends and family visited them freely, and they could see them in private if they wished. Residents were offered choices. Staff were seen to ask residents opinions, for example, where they would like to sit, what they would like to eat, and what they would like to watch on television. All of the residents spoken with said that they were provided with choice. Residents were free to move around the home and spend time in their bedroom, or communal areas as they wished. The homes menu was varied and appeared healthy. All of the residents spoken with said the food was very good. The menu evidenced that choices were available. Staff and residents said that they could have different meals to the menu if they wanted. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 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 complaints procedure in operation ensured residents concerns were taken seriously. An adult protection policy and procedure was in operation to protect residents from abuse EVIDENCE: A written complaints policy was available to residents and staff. The policy included information on how to contact the local office of the CSCI, and stated that complaints could be referred to the Commission at any stage. A record of complaints was kept. These detailed the action taken and the outcome of the complaint. All of the staff and residents spoken with had confidence that the homes manager and owners would listen to them and take any concern seriously. A written adult protection procedure was available to staff. The staff spoken to were aware of the procedures to follow should they suspect abuse. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. The home was clean, well decorated and well maintained to provide residents with a comfortable place to live. EVIDENCE: An inspection of a proportion of the environment was undertaken. The home was well maintained. Furniture and fittings appeared in good condition Communal areas were well-decorated and provided with pictures and ornaments to create a homely atmosphere. All of the residents said that they were very happy with the accommodation provided. The home was very clean. Staff were provided with equipment, such as aprons and gloves, to enable them to adhere to hygiene procedures. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 16 One identified carpet was in need of replacement due to unpleasant odours. This was discussed with the manager. There were a number of items stored behind the tumble dryer in the laundry. This practice posed a potential hazard. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. A programme of National Vocational Qualifications (NVQ) was in operation, to keep residents safe. Residents were protected by the homes recruitment procedures. Staff were provided with training to ensure they were competent to do their jobs. EVIDENCE: The staff rotas for the week of this inspection, and a four-week period prior to the inspection were examined. This indicated that agreed levels of staff were being maintained. The residents spoken with said that enough staff were provided. A programme of NVQ training for staff was ongoing. Of the 39 care staff, 19 (50 ) had achieved NVQ level 2 in care. Further staff were in the process if completing the training. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 18 Three staff recruitment records were inspected. They did not contain all of the required information. Application forms had been completed, which detailed full employment history. Two written references had been obtained, one from the most recent employer. Criminal Records Bureau (CRB) checks had not been completed on all staff prior to employment. However, as a measure to uphold residents’ safety, Pova first (Protection of Vulnerable Adults) checks had been undertaken Records of staff training were inspected. Staff were provided with induction training. Considering the nature of the residents and some of the unpredictable behaviour displayed, the inspectors suggested that training on specialist subjects such as managing challenging behaviour, and acquired degenerative conditions, were provided to staff to improve their knowledge. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 19 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): 31,32,33,35,36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager’s leadership style benefited residents and staff. The quality assurance system required improvement to ensure residents and their representatives were fully informed about systems within the home. Resident’s finances were safeguarded by the procedures in place. Staff were appropriately supervised, to offer support and maintain their skills. A health and safety system was in operation, to protect residents and staff. The training records required attention in order that safe procedures were followed. There were gaps in mandatory training. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 20 The inspectors identified a number of staff that had not had fire drill training at the required interval, posing a potential risk. EVIDENCE: The manager displayed a strong sense of commitment to her job. She appeared well organised and a good leader. The staff spoken with said that the manager was supportive and approachable. The quality assurance system in operation was not complete and there were no findings published in relation to this. Whilst the manager confirmed that monthly monitoring visits were being undertaken, reports from these visits were not consistently provided. Small amounts of residents’ spending monies were kept. Records of these were inspected. All transactions were recorded and accompanied by two signatures. The records corresponded with the amounts of money kept. Money was stored securely. Three staff supervision records were examined. These evidenced that staff were not provided with supervision at the recommended frequencies. Supervisions covered relevant topics such as the care workers role and training needs. Health and safety systems were checked and maintained. The fire records inspected evidenced that fire alarms were checked on a weekly basis from different call points. However, a number of staff had not received fire training at the required intervals. The manager committed to taking immediate action in relation to this issue. Since this site visit, written evidence to confirm that this training had taken place had been forwarded to the CSCI. A rolling programme of mandatory training was in operation, however, records inspected evidenced some gaps in food hygiene and health and safety training. A staff-training matrix identified when refresher training was required. The majority of the environment inspected appeared safe. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 21 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 3 X 3 3 3 X 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 2 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 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 2 Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 4 Standard OP12 OP26 OP26 OP29 Regulation 12 23 23 19 Requirement Discussions with residents must take place regarding trips out of the home. The storage of items behind the tumble dryer must cease The identified carpet must be replaced. Where a Pova first check has been obtained, the appropriate CRB disclosure process must still be completed. All staff must be provided with relevant specialist training in dementia and managing challenging behaviour. The responsible individual must distribute copies of his unannounced monthly visits to the home as required by regulation. Previous timescale of 31/01/06 was not met. An audit of mandatory training must be undertaken. Relevant training must be provided where gaps have been identified All staff must have up to date Health and Safety and Food Hygiene training. DS0000062445.V315194.R01.S.doc Timescale for action 05/03/07 05/01/07 05/03/07 05/03/07 5 OP30 13 28/05/07 6 OP33 26 05/03/07 7 OP38 13 05/03/07 8 OP38 13 05/03/07 Brantwood Hall Care Complex Version 5.2 Page 23 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 2 Refer to Standard OP33 OP36 Good Practice Recommendations The results of any quality assurance surveys must be published and made available to all interested parties. All staff must be provided with supervision at the minimum frequency of 6 times each year. Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Brantwood Hall Care Complex DS0000062445.V315194.R01.S.doc Version 5.2 Page 25 - 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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