Inspection on 07/07/05 for Breach House

This inspection was carried out on 7th July 2005.

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

Breach House 11/09/06

Breach House 03/11/05

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 Yvonne South Unannounced 7 July 2005 11:00 am 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. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Breach House Address Holy Cross Lane, Belbroughton, Stourbridge, West Midlands DY9 9SP 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) 01562 730021 Mr Michael Gordon Hucker Mrs Julie Anita Head Care Home 26 Category(ies) of OP Old age both genders (26) registration, with number PD(E) Physical disability over 65 both genders of places (26) DE(E) Dementia over 65 both genders (26) Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration to those recorded on the previous page. Date of last inspection 25 January 2005 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. Twentyfour 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 E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over four hours commencing at 11am. The inspector was shown around the home and examined samples of documents and records. She was assisted by the manager Mrs Julie Head, two staff and three service users. What the service does well: What has improved since the last inspection? Since the last inspection improvements have been made in redecoration and the re-carpeting of some areas following the installation of a new lift, and some bedrooms. Safety restrictors have been fitted to all windows above ground level. Improvements have been made to the recruitment process to improve the safe selection of suitable staff. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 6 The strong commitment to staff training has enabled people to continue to develop their knowledge, skills and expertise in caring. 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 E52 S18495 Breach House V237558 070705.doc Version 1.40 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 Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 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) 3,4,5, Time is taken for mutual assessments to take place and ensure each placement is appropriate. The service only accommodates people whose needs can be met by the service. EVIDENCE: The manager described how the assessment process commenced with the first contact made by or on behalf of a prospective service user. Everyone was invited to come and see the home and talk about their wishes and needs. Ideally people would spend the day and enable a mutual assessment to take place. Then a trial stay of two months was usual. There was documentary evidence in the three files assessed that a detailed assessment had been undertaken and an initial care plan had been put in place. Three service users confirmed that they had been assessed, received all the information they required to help them come to a decision and were happy with their choice of home. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 9 The manager confirmed that the home only offered permanent accommodation to people whose needs could be met. If they subsequently deteriorated beyond the service provided they were supported to find alternative accommodation and care. There was a commitment to staff training. A member of staff and training records confirmed this. Service users’ praise of the staff was overwhelming. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 Detailed information regarding care needs is readily available in care plans to advise and assist staff to consistently providing a good quality, individual service. The health care needs of people are fully met by staff, the primary health care team and specialists. Medication is well managed for the health, wellbeing and independence of service users. Privacy and dignity is respected throughout the service. Service users who die in the home receive full support and care. EVIDENCE: Three service users’ plans were assessed. The documents were clearly and logically organised to a high standard and contained a wealth of detailed information describing how the individual care needs were to be met. All plans had been appropriately reviewed. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 11 There was little evidence of service user involvement. However some documents had been signed by the service user. A service user said that she could not recall any involvement but it was seen that she had agreed and signed her plan. It was recommended that if people did not want to be involved or sign their records a statement should be made by the member of staff to this effect. There was detailed information in the care plans of all aspects of health care. Contacts and advice was sought when necessary from Gps, district nurses, specialist health care workers and community health care workers. It was demonstrated that when the home was no longer able to meet a person’s needs action was appropriately taken. The manager said that she was about to embark on a project using the ‘MUST’ nutritional assessment tool, hip protection assessments and in depth assessment of continence with all service users. Service users confirmed that they saw the doctor when they wished or when the staff thought it wise. They confirmed that their health was well looked after. Medication records were assessed for the three service users. The requirement made in the previous inspection report that all hand written entries be checked and initialled by two members of staff had not be done for this week. The manager said that usually this was done as required. Other records had been appropriately maintained. Medication storage was acceptable with the exception of a designated lockable medication fridge. Currently a lockable box was used in the kitchen fridge. This is unacceptable. One person self-administered her insulin. It was observed that staff had been appropriately trained to assist her and monitor her condition. The manager said that this training was about to be up-dated. It was recommended that the parameters regarding BM tests would be most useful if filed with the BM test results for quick east reference. Service users were confident that their medication was being well managed and they trusted the staff to look after them. Their records indicated that advice and assistance had been sought from doctors and the pharmacy when needed. It was observed that staff treated service users with respect and kindness. The housekeeper, the cook and the care staff were observed to spend time with the people who were living in the home. Relatives of a prospective service user were shown around with skill and attention. All questions appeared to be answered and reassurance given. Service users said that the staff were kind, good humoured, helpful and kind. The manager confirmed that the staff team was composed of a lovely group of people who really cared about the service users in the home. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 12 The provision of keys to bedroom doors and lockable storage was noted in individual care plans. It was observed that en-suite facilities did not have door locks fitted. These were recommended. The records were seen of the last service user to die in the home. They demonstrated that all health and physical care needs had been met. Medical assistance had been sought and links had been maintained with next of kin. Limited information was available in individual records regarding wishes and there was some discussions as to how this could be addressed without causing distress or anxiety. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 13 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, Service users are happy in the home and organise the day and their activities to their liking. Individual choices and decisions are respected. Links are maintained with family, friends and the community according to individual wishes and choice. A wide choice of good quality meals are provided and dietary health needs are being met. EVIDENCE: An activities programme was displayed in the corridor of the home describing events in which service users could participate if they chose. Aromatherapy hand massage was being provided during this inspection. The hairdresser also visited. The activities organiser held bingo, ball games, craft and quiz sessions. A ‘Variety Fanfare’ was soon to take place in the home and a musical entertainer regularly visited. A monthly church service was held in the home. A church was attended in the community and the manager said that transport had been provided in the past to help a service user maintain her links with her faith and church. Service users confirmed that there were interesting events taking place. In addition the grounds were spacious and attractive, they enjoyed their own music, doing crosswords and suduco, reading and watching the television. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 14 Visitors were seen to be welcome and the manager said that information was available in the statement of purpose for the home. Service users were able to receive their visitors in their room or in the communal rooms. Some people were able to go out with their family and friends. The home had a strong link with the village of Belbroughton and the local school children came and gave musical performances on occasions. Service users confirmed that they were able to make decisions in their lives. They chose when they rose and retired each day, when they used the communal rooms or enjoyed their own company. They managed their own finances, with the help of their family if necessary. They had their personal possessions around them in their rooms, including furniture in some cases. The service users said that the standard of the food and the range of choice were very high. The person who was a diabetic was particularly impressed at the trouble that was taken to ensure she had a choice of meals to her liking. The cook demonstrated that a wide choice of meals was always available. The menu demonstrated that birthdays were acknowledged and it was confirmed that a record of meals provided was maintained. It was advised that a more detailed record needed to be kept for people on special diets. The cook said that he would start this immediately. Some service users were observed to be enjoying their lunch in the dining room and others in the lounge. Meals could also be taken in their bedrooms if they preferred. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 15 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) These standards were not assessed in full during this inspection. EVIDENCE: The manager said that no complaints had been received since the previous inspection. A requirement had been made following the previous inspection that all staff should receive fuller training in adult protection. This was now being done. Therefore the requirement had been met. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 16 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) These standards were not assessed in full during this inspection. EVIDENCE: Three requirements had been made following the previous inspection concerning the environment. The offensive odour in one bedroom had been addressed and was being well managed. Therefore the requirement had been met. All windows above ground level had been fitted with restrictors so that people could not climb or fall out of them. Therefore the requirement had been met. Work was in progress to fit radiator covers to all radiators. This requirement had not been completed within the time scale. The manager said that the work would be completed before the winter. Therefore it will be repeated in this report with a new timescale. A full inspection of the premises was not undertaken. However it was noted that everywhere was cleaned to a very high standard and a credit to the staff. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 17 The manager said that recently a new lift had been installed. The landings had been redecorated and new carpets laid. Several bedrooms had been redecorated and carpeted. It was observed that the toilet seat was missing in one communal toilet and the door lacked a lock. The conservatory was in need of re-carpeting. The manager said that it was due to be re roofed and completely refurbished. The floor tiles in one corridor were cracked in several places. This must be addressed. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 18 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) These standards were not fully assessed during this inspection. EVIDENCE: Following the previous inspection two requirements were made relating to staff recruitment. The application form had now been reviewed and a sample file indicated that full employment history was explored. Therefore this requirement had been met. Two written references were obtained before an applicant was appointed. Therefore this requirement had been met. A senior care assistant said that she was happy in her work and there was good access to training. She had achieved an NVQ 3 qualification. The manager said that four more staff were about to start their NVQ training and when completed all staff would be NVQ trained. Further training was also planned in Diabetes, BM testing and fire safety. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 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 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) These standards were not assessed in full during this inspection. EVIDENCE: There had been one requirement in this section arising out of the previous inspection. The manager said that this was being address. The registered provider was developing a quality assurance system as required. As the work has not been completed and implemented the requirement will be repeated in this report. The manager said that she had achieved an NVQ 4 qualification and nearly completed the training to achieve the Registered Managers Award. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 20 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 x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 21 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 9 Regulation 13(2) Requirement Handwritten entries on medicine administration records (MAR) must be checked and initialled by two memebers of staff. (The records indicated that this requirement had previously been met but not on the week of this inspection.). Medication that needs to be stored at a low temperature must be kept in a designated lockable medication fridge. Covers most be fitted to all radiators unless they are of the cool touch type. The following must be done: 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. A quality assurance system must be developed in line with standard 33. Timescale for action From the date of the inspection. 2. 9 13(2) 30th September 2005 30th September 2005 31st December 2005 3. 4. 38 19 13 13 5. 33 31st December 2005 Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 22 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 7 10 Good Practice Recommendations Evidence of the involvement of service users in their care planning must be more clearly evidenced. It is recommended that locks are fitted to ensuite facilities to enhance access to privacy. Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI Breach House E52 S18495 Breach House V237558 070705.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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