Inspection on 03/11/05 for Breach House

This inspection was carried out on 3rd November 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

Breach House 11/09/06

Breach House 07/07/05

Breach House 25/01/05

Breach House 09/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Breach House Holy Cross Lane Belbroughton Stourbridge West Midlands DY9 9SP Lead Inspector Y South Unannounced Inspection 3rd November 2005 09:15 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 Breach House DS0000018495.V251195.R01.S.doc Version 5.0 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. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Breach House Address Holy Cross Lane Belbroughton Stourbridge West Midlands DY9 9SP 01562 730021 01562 73002 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) Mr Michael Gordon Hucker Mrs Hilary May Hucker, Miss Karen Ann Hucker Mrs Julie Anita Head Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26), of places Physical disability over 65 years of age (26) Breach House DS0000018495.V251195.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home provides a service for older people but may also accommodate one named person under the age of 65 who has dementia. 7th July 2005 Date of last inspection Brief Description of the Service: Breach House provides residential care for older people. Service users are expected to be mentally alert and mobile (with walking aids if necessary) on admission. Subsequently the home endeavours to provide care for as long as it is needed and for as long as it can meet a service user’s needs. The premises consist of a three storey former farmhouse, which has been adapted and extended for its present purpose. It occupies a level site with two acres of grounds and is located half a mile from Belbroughton village at the end of a private road some two hundred and fifty yards in length. Service users are accommodated in single bedrooms, although some are large enough for double occupation. Twenty-four rooms have en-suite facilities. One bedroom is served by a stair lift, and the others by a passenger lift. There are communal lounges, a conservatory, a dining room, assisted bathrooms and toilets. The business is family owned and a manager is employed to take responsibility for the day-to-day running of the home. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over two and three quarter hours from 9.15am until 12 md. The registered manager assisted the inspector. She also spoke to two residents, the residents in the lounge and the staff on duty. A partial tour of the building and a range of documents were seen. The focus of the inspection was on the recommendations that had been made following the previous inspection, and standards concerned with protection and rights, staffing and quality. A service questionnaire was completed by the home prior to this inspection and returned to the Commission for Social Care Inspection. The manager was asked to distribute other questionnaires regarding the service to residents, relatives and health care professionals. The completion of these is voluntary but proves useful in assessing the various views that are held. Eight responses were received. What the service does well: This welcoming home is situated in attractive gardens surrounded by lovely countryside. The house is kept in a very clean condition and is comfortably decorated and furnished. The staff relate very well to the residents and care for them with kindness and understanding. Residents confirmed that the staff cared for them well and they enjoyed their food and the range of activities and social events that were arranged for them to participate in. Comments in questionnaires that were returned included; The home is very well run. The building is always spotlessly clean and free from unpleasant odours. Very impressed with the standards of care. The records are maintained to a very high standard and provide a sound structure that supports the quality care that is provided. There is a strong commitment to training and the benefits of this are seen in the care service that is provided. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 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. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 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 Breach House DS0000018495.V251195.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed during this inspection. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 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): EVIDENCE: Following the previous inspection a recommendation was made that there was evidence of the resident’s involvement in developing their care plan. The records showed that this was now routinely recorded. Two requirements were made regarding medication. During this inspection it was observed that medication records were signed when the medication was received and checked into the home and a medication fridge had been purchased and was being acceptably used. The proprietors had not accepted the recommendation that privacy could be enhanced if locks were fitted to en-suite facilities. Locks are currently fitted only to bedroom doors. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed during this inspection. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 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): 16, 17, 17 Residents, supporters and staff had the information they needed to guide them in raising their concerns. The legal and civil rights of residents were protected by the policies, procedures and practises in use. Staff were trained to identify and protect residents from abuse. EVIDENCE: A complaint procedure was available providing guidance for residents, their supporters and staff. The manager said that everyone received their own copy when they came to the home either as a resident or an employee. A minor amendment was needed to the procedure so that it clearly stated that people could contact the Commission for Social Care Inspection at any time. The home had received no complaints since the last inspection. No advocacy services were currently used in the home but information was given to each new family of ‘Care Aware Advocacy Services’ and several families had told the manager that this had been useful to them in ensuring the resident obtained their financial rights. The manager said that all residents were on the electoral roll and were supported to use their postal votes at election time. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 Page 12 A wide range of policies and procedures were available concerning the protection of vulnerable people. Of a staff team numbering nineteen persons, seventeen had received training and courses were booked for the remaining two. This is a commendable achievement. Residents were able to have personal monies held for them, and if necessary managed for them, in secure storage in the home. Records were maintained to a high standard and receipts and signatures obtained. Information was available instructing staff that they were not permitted to benefit from gifts or bequests from residents nor were they able to assist in the making of residents’ wills. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 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 the following standard(s): 19. 26 Residents are able to live in clean well-maintained accommodation that is suited to their needs and wishes. Systems and work practices reduce the risks of cross infection. EVIDENCE: Following the last inspection a requirement was made that a toilet seat needed to be replaced, cracked floor tiles in a corridor needed to be replaced, the conservatory needed to be repaired and refurbished and a lock with an emergency over-ride needed to be fitted to a communal toilet door. A timescale was set for 31st December within which the work needed to have been completed. At the time of this inspection the conservatory roof had been repaired. A requirement to complete the outstanding work within the timescale will be included in this report. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 Page 14 A partial tour of the home was undertaken. It was very clean and a credit to the staff concerned. The maintenance record indicated that repairs were swiftly carried out. The manager said that since the last inspection rooms had been redecorated and carpeted, a new lift had been installed, and the car park had been resurfaced. A programme of routine maintenance and renewal of fabric and decoration was not available. (Standard 19.2). The manager said that she was consulted by the proprietors and felt able to make suggestions and requests. The proprietors may have used these to make a formal structured written plan. Such a plan could usefully be incorporated into the quality assurance system. Laundry facilities were acceptable although a little untidy. Personal protective equipment was readily available and liquid soaps and disposable towels were appropriately placed. A range of policies, procedures and training provided advice and guidance for the staff on infection control. A tub of personal ointment left in a communal bathroom was swiftly returned to its owner’s bedroom. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, The home is staffed by sufficient, well-recruited and trained staff. First aid and dementia care training is needed so that staff are able to respond to the specific needs of individuals. EVIDENCE: The duty rosters indicated that staffing and skill mix was acceptable through the day and night. There was one person on long-term sick leave and two new staff had been recruited and would soon start work. The set of records that was inspected indicated that an acceptable recruitment procedure was used, records were in order and appropriate references and checks had been made and received. Records were seen that indicated that induction training was undertaken. Training in the five core subjects was pursued. First Aid training needed to be updated, and there was a need for training in dementia care, as the home was registered to provide care for people with dementia illnesses. The manager said that she was in the process of organising the training this month. The manager was studying for the Registered Managers Award. Two care staff were trained to NVQ level 3 and two staff were trained to NVQ level 2. Two people were on NVQ level 3 courses and two people were on NVQ level 2 courses. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 Page 16 Nine of the fifteen care staff had NVQ qualifications or were working towards achieving them. This is an excellent commitment to training and the benefits are apparent in the working practice seen in the home. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 38 A quality assurance system needs to be implemented to identify areas were the service can be developed and improved. The financial system in use protects the interests of the residents. EVIDENCE: Following the last inspection a requirement was made that a quality assurance system should be developed in line with all the elements of standard 33. The manager said that one of the proprietors was working on a system and expected to complete and implement it within the timescale that had been set. Therefore the requirement will be repeated in the report. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 Page 18 A requirement was made that corridor radiators be covered to prevent the hot surfaces causing accidental burns. This work had been completed. A full range of health and safety policies and procedures were available and staff were receiving appropriate training. Moving and handling training updates were scheduled to be given the week after the inspection. Equipment and systems were regularly checked and serviced. A manual of risk assessments was available and the records indicated that the manager undertook a risk assessment audit every month. The fire log contained evidence that fire safety systems and equipment were being regularly checked and staff were receiving suitable training. The records were maintained to an excellent standard. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 X X 2 Breach House DS0000018495.V251195.R01.S.doc Version 5.0 Page 20 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 Standard OP16 Regulation 22 Requirement Information must be available in the complaint procedure that people can contact the Commission for Social Care Inspection at any time. Timescale for action 31/12/05 2 OP19 13 3 OP30OP38 13 4 OP33 24 The following must be done: 31/12/05 1.The toilet seat must be replaced. 2. The floor covering in the corridor must be attended to. 3. The conservatory must be repaired and refurbished. 4.Communal toilets must be fitted with door locks that ensure privacy but enable emergency access. There must be at least one 31/03/06 member of staff with a valid accredited First Aid at Work (four day course) certificate on duty day and night. Care staff must receive training in dementia care. A quality assurance system must 31/12/05 be developed in line with all the elements of standard 33. Breach House DS0000018495.V251195.R01.S.doc Version 5.0 Page 21 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 Breach House DS0000018495.V251195.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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