Inspection on 09/05/07 for Breadalbane

This inspection was carried out on 9th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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Snydale Care Home

Abbey The

Whiteley House

Larchfield Manor

Hawkhills

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 Breadalbane Breadalbane 2 Park Avenue Castleford W Yorks WF10 4JT Lead Inspector Tony Brindle Key Unannounced Inspection 9th May 2007 11:30a 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 Breadalbane DS0000068769.V329972.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. Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Breadalbane Address Breadalbane 2 Park Avenue Castleford W Yorks WF10 4JT 01977 518794 01977 518794 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) Ecce Cor Meum Ltd Non registered Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (15), Physical disability over 65 years of age (5) Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1st Inspection since change in owner in January 2007 Brief Description of the Service: Breadalbane is a care home provides accommodation and personal care for up to 15 older people who require residential care. The home is privately owned and is situated in a residential area of Castleford. The home is a large converted house, which has been adapted and extended to provide accommodation over three floors. There is a passenger lift operating between the floors. The home has one double bedroom; the remainder are for single occupancy. Accommodation provided in the newer part of the house offers en-suite facilities. In May 2007, the weekly fees at Breadalbane ranged from £380 - £395. The service provider ensures that information about the service is available to people by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the care home. The inspector spoke with people living at the home, the acting manager and staff members. The inspector looked around the home and looked at some of the paper records. Before the visit to the home took place, the acting manager was asked to complete a pre-inspection questionnaire. This she did. Surveys were sent out to people living at the home, their relatives, staff members and health and social care professionals who have dealings with Breadalbane. Many of the surveys were returned to the Commission, and the feedback that people gave was positive. Some of things people said included: • “I really love living at Breadalbane”. – Person living at the home • “The staff are really good, and I like going out, and like the way that people help me”. - Person living at the home • “My relative is supported well at Breadalbane”. – Relative of a Person living at the home • “The staff are very supportive, and appear to know what they are doing. They always come across as professional”. – Healthcare Professional The inspector would like to take this opportunity to thank everyone for their hospitality and assistance during this inspection visit. What the service does well: People considering moving into the home are given sufficient information about the home and how the manager and staff are to meet their needs. The needs of people are assessed and they are given a contract which clearly tells them about the service the will receive. People are involved in decisions about their lives, and play an active role in planning the care and support they receive. People are able to make choices about their life style, and supported to develop their life skills. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, that will help them to look into issues and problems. People’s rights are promoted by safeguards that protect them from abuse. The physical design and layout of the home enables people to live in a safe, well-maintained and comfortable environment, which encourages independence. Staff in the home is trained, skilled and are provided in sufficient numbers to support the people who use the service. The management and administration of the home is based upon openness and respect. The acting manager operates a quality assurance system that promotes the well-being and safety of people living at Breadalbane. Breadalbane DS0000068769.V329972.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. Breadalbane DS0000068769.V329972.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 Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 6. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Prospective people to the home and their representatives are given sufficient information about the home and how the manager and staff are to meet their needs. People have their needs assessed and are given a contract which clearly tells them about the service they will receive. EVIDENCE: The acting manager spoke about how the assessment process focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the person’s needs. Two person living in the home spoke about being given the opportunity to spend time in the home before moving in. These people had had the chance to visit the home, talk to the staff, have a look at the building, talk and spend time with people already living in the home. The manager confirmed that all Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 9 the people living in the home receive a contract that details, and the records show that the person living in the home or their family member has agreed this contract. The service has a statement of purpose and other information setting out its aims and objectives, the range of facilities and services it offers to people. The information was seen to include the terms and conditions of occupancy. One person living in the home spoke about how information is explained to them so that they can fully understand it. Feedback from people living at the home via surveys showed that they did receive enough information about the home before they moved in which helped them decide if Breadalbane was the right place for them. The acting manager explained that the a decision about admission is based upon a wide range of evidence and the records show that person and their relatives are kept informed and involved in the decision making process as much as possible. The manager explained that Intermediate Care is not provided at Breadalbane. Breadalbane DS0000068769.V329972.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: The care plans seen are well written and focus on the person and have been signed by either the person or their representative. The care plans were seen to look at all areas of the person’s life. The acting manager said that the care plans are a working document and there is evidence to show that the plans are reviewed regularly. The person living in the home said when their care plan is reviewed they are involved in the process. The care plans were seen to include a comprehensive risk assessment, which again is reviewed regularly in order to make sure people needs are being met properly. One person said that the staff talk to them about their care and support, and they encourage them to put forward their point of view about how to be supported. Feedback from people living at the home via surveys showed that Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 11 they always receive the care and support they need. They said that the staff always listen to them, and are always available when they needed them. The acting manager spoke about how the management of risk is positive and that the staff address safety issues whilst aiming to improve a person’s quality of life and promote independence. Where limitations are in place, the decisions have been made with the person and the records confirmed this. One person living in the home said that the staff always talks to them about activities and about how to make sure they are safe when taking part in different activities both inside and outside the home. The records show that there are procedures in place to ensure that people using the service are informed of their rights to confidentiality. One person living at the home said that they understand when staff may have to share personal information. Contact details for advocacy services were seen to be available within the home. The medication records and storage were found to be satisfactory. One person living at the home said that the staff help them with their medication, making sure that it is looked after properly, and making sure it is given to them at the right time and in the right quantity. Breadalbane DS0000068769.V329972.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service are able to make choices about their life style, and are supported to develop their life skills. EVIDENCE: Discussions with the acting manager and members of staff showed that the service has a strong commitment to enabling people who use services to maintain their skills, including social, emotional, communication, and independent living skills. One person spoke about how they are supported to develop and maintain important personal and family relationships, and are able to access information and specialist guidance about healthcare. The acting manager said that good, nutritious food and drink are important in keeping and improving people’s health and well being. Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 13 One person living at the home said that their preferences for food and drink are supported by the cook and staff at the home. This person added that if someone didn’t want what was on the menu then an alternative would be offered and given. One person living at the home said, “Enjoying your food and having your own needs and choices met is an important part of the day-to-day life. The staff make sure you get what you need here.” Feedback from people living at the home via surveys showed that they either usually or always enjoy the meals at Breadalbane. One person living at the home said that the social events, entertainment and activities provided at Breadalbanel are organized so that people can join in if they want to. Feedback from relatives showed that they are happy with the activities offered to their relative, and were satisfied that sufficient stimulation and physical activities were provided at the home. Feedback from people living at the home via surveys showed that on the whole, they are happy with the activities arranged by the staff at the home, however, one person said that there were not enough day trips out of the home. The owner of the home said that he was looking into ways in which further activities could be provided. Activities are to include things such as video nights, reminiscence sessions and outings to places of interests. Breadalbane DS0000068769.V329972.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure. People’s rights are promoted by safeguards that protect them from abuse. EVIDENCE: One person living at the home said that they felt confident about talking to the staff and acting manager about any problems or complaints they had about their care and support. This person added that they were aware of the complaints procedures and knew how to access it and use it. The records confirmed that there is a straightforward and accessible complaints procedure, and also that the acting manager had received one complaint since January 2007. She was able to explain the circumstances surrounding this complaint, and the records showed that the complainant was satisfied with how the complaint had been dealt with and was happy with the outcome. Feedback from relatives showed that they are aware of the complaints procedure and that they would feel confident approaching the acting manager or owner about a concern regarding the care of their relative. Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 15 Feedback from people living at the home via surveys showed that they know how to make a complaint. One person living at the home said that the staff are very caring and helpful, and that they are aware of the need to protect people. They added that the staff have been on training courses about how to protect people and what to do if someone was being abused. The records confirmed that staff have attended safeguarding training, and the acting manager gave a clear explanation of what she would do if she suspected that someone had been abused. A staff member confirmed that they have access to not only the home’s safeguarding policy and procedure but also the local multi-agency. Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The physical design and layout of the home enables people to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: One person living at the home said that they really like living at Breadalbane and that rather than it feeling like a care home, it feels like a really good hotel. Another person said “The home is always kept nice and tidy and that the staff take a pride in keeping the place clean”. The manager said that the staff ensure that the physical environment of the home provides for the individual requirements of the people who use the service, adding that the staff try and promote as much independence as possible, encouraging people to do as much as possible around the home. Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 17 The records show that risk assessments are in place, which inform staff of the capabilities of people living at Breadalbane. Feedback from relatives showed that they are happy with the environment at Breadalbane, and see it as a comfortable, inviting and a homely place to live in. Feedback from people living at the home via surveys showed that in their experience the home is always fresh and clean. Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 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 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Staff in the home are trained, skilled and are provided in sufficient numbers to support the people who use the service. EVIDENCE: One person living at the home said that they experience good quality support and care, adding that the staff are always professional in the way that they work. This person felt confident that the staff providing them with support and care have a good knowledge of how to do the job and the skills to do the work. The acting manager explained that when new staff start work, they are helped to get experience of working with people as part of a planned training programme. The records confirmed this. The manager explained that the recruitment of good quality carers is seen as really important to the delivery of an good service, and continued to say that the recruitment of the right person for the job is always seen as more important than the filling of a vacancy. She believes that the people living at Breadalbane can be confident that at all times the number of staff who are trained and who have the necessary skills will be sufficient to meet their support and care needs. Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 19 The rotas show that the service has enough staff available at all times to support the needs, activities and aspirations of the people using the service in an individualised and person centred way. The acting manager has only worked at the home for a short period of time, and has applied to be registered with the Commission. Alongside other work that she has already undertaken since starting work in the home such as developing a better assessment tool and an activities recording system, she is looking at ways in which a more effective staff development scheme can be set up and an effective yearly training plan for all the staff. The training records show that staff are well trained and have attended many of the necessary training and refresher training courses. Feedback from staff via surveys showed that they are happy with the training offered by the service and feel that training is an important way of developing skills so as to make sure that people’s needs are met. Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The management and administration of the home is based upon openness and respect. The acting manager operates a quality assurance system that promotes the well-being and safety of people living at Breadalbane. EVIDENCE: One person living at the home said that they feel safe living in the home and that the staff are aware of safety issues. The records confirmed that the acting manager and staff made sure that risk assessments are carried out and that if hazards are identified then actions are taken to reduce any risks to people’s health and wellbeing. Staff at the home said that the acting manager has an open, positive and inclusive approach to the work she does, and that she communicates a clear Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 21 sense of direction and leadership to the staff. The records show that there are quality assurance and quality monitoring systems in place that are based on seeking the views of people who live in the home. The acting manager said that she had only worked in the home since January 2007, and that she had applied to be registered with Commission. The acting manager explained that people control their own money either themselves, or with the aid of their relatives. One person living at the home said that said that the staff regularly supports them to visit the bank and deposit or withdraw money. The records show that care staff receive formal supervision at least 6 times a year. One staff member said that supervision covers aspects of practice, the aims of care in the home and their own career development needs, which are linked to the needs of people living at the home. Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Breadalbane DS0000068769.V329972.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? no 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations Further development of the choice of internal and external activities available to people living at the home would further enhance their quality of life. Breadalbane DS0000068769.V329972.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. 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