Inspection on 17/09/08 for Breckside Park Residential Home

This inspection was carried out on 17th September 2008.

CSCI found this care home to be providing an Adequate service.

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

Breckside Park Residential Home 06/11/09

Breckside Park Residential Home 05/04/07

Breckside Park Residential Home 03/11/06

Breckside Park Residential Home 17/05/06

Breckside Park Residential Home 15/11/05

Breckside Park Residential Home 20/07/05

Breckside Park Residential Home 01/02/05

Breckside Park Residential Home 13/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 26/11/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Breckside Park Residential Home 10 Breckside Park Anfield Liverpool Merseyside L6 4DL Lead Inspector Daniel Hamilton Unannounced Inspection 17th September 2008 09:15 X10029.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 Breckside Park Residential Home DS0000025331.V362643.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 and Care Homes for Adults 18 – 65*. 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. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Breckside Park Residential Home Address 10 Breckside Park Anfield Liverpool Merseyside L6 4DL 0151 260 6491 F/P 0151 260 6491 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 Keshav Khistria Mrs Kirti Khistria Vacant Post Care Home 26 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (3), Old age, of places not falling within any other category (21), Physical disability (2) Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate four (4) named persons under the age of 65 years in the overall number of twenty six (26). 31st January 2008 Date of last inspection Brief Description of the Service: Breckside Park is a registered care home providing personal care for up to 26 residents who are over the age of 65 years. The home has been granted variations to the registered status to provide the care and support to named people who are under the age of 65 years. The home is situated in the Anfield area of Liverpool and is close to parks, shops and public transport routes. Communal space within the home consists of 2 lounges, a dining room and a large conservatory. The home has 26 single bedrooms five of which have an en-suite WC. The home benefits from a large enclosed rear garden and further garden areas to the side and front aspects of the home. A copy of a Service User Guide is displayed in the reception area of the home and a Statement of Purpose is stored in the office. These documents provide information on the service provided. The current fee for residing at Breckside Park is £322.00 per week. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place over one day and lasted approximately 10 hours. Twenty-four people were being accommodated in the home at the time of the visit. A partial tour of the premises took place and observations were made. A sample of care records were examined as part of a case tracking process and a selection of staff and service records were viewed. The Registered Person (owner), acting manager, residents and staff were also spoken with during the visit. Prior to the inspection, survey forms were distributed to a number of staff, residents / or their relatives, to obtain additional feedback about the home. The Acting Manager also completed an Annual Quality Assurance Assessment to provide general information on the service. All the key standards were assessed and action taken in response to the previous requirements and recommendations from the last key inspection in April 2007 and the random inspection of 31/01/08 was reviewed. What the service does well: Breckside Park presented as a warm and caring environment. Staff were seen to treat the residents with respect and observed to be attentive to the support needs of the people using the service during the inspection. The people living in the home appeared relaxed and comfortable in their home environment and were observed to communicate and engage with the staff team in a positive manner. Residents spoken with were complimentary of the care provided and comments included; “The care staff are nice”; “The standard of care provided is good” and “I can’t fault the people who look after us.” Residents spoken with confirmed they were able to follow their preferred routines and exercise choice and control over their lives. A programme of daily activities was in place which provided a choice of activities for people to participate in and the people using the service confirmed they were generally satisfied with the food provided. Comments included; “The meals are nicely prepared and there is always a choice and plenty to eat” and “I always enjoy the main meal of the day and have no complaints about the standard of catering.” Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 6 Systems had been established to safeguard vulnerable people from abuse and to respond to complaints. Feedback from residents confirmed they had no complaints about the service and were confident that the acting manager and staff would listen and act upon any issues of concern. For example, a resident reported; “I am sure that if I made a complaint Lynn [the manager] would deal with the matter to my satisfaction.” What has improved since the last inspection? What they could do better: The service had developed a statement of purpose and service user guide. Arrangements should made to review the documentation, to ensure people have up-to-date and accessible information on the service. Likewise, the terms and conditions of residency should be updated to include the room number allocated to each resident and the details of the person or organisation responsible for fees. This will help to clarify individual rights and responsibilities. Assessments viewed provided basic information on the needs of the people using the service. Comprehensive assessments of need should be undertaken by trained staff, which are dated and include information on equality and diversity information. This will ensure a more holistic assessment of needs is undertaken for new residents. Risk assessments should also be kept under review and clearly identify how potential areas of risk are to be managed. This will ensure the welfare of the people using the service is safeguarded. At the time of the visit a medication policy was not in place at the Beackside Park and some issues of concern were noted regarding the administration and recording of medication. Medication must be stored, administered and documented appropriately at all times so as to safeguard the health and well being of residents. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 7 A quality assurance system had been developed since the last visit however the system had not been maintained for a period of time and required further development to ensure the service is run in the best interests of the people using the service. Systems had been developed to manage money held on behalf of residents. The registered person should review the arrangements for the management of residents’ personal finances, in consultation with other professionals, where there is concern regarding the welfare of the people using the service. This will help to safeguard the welfare of vulnerable people. Despite a requirement at the last visit it was noted that staff had commenced employment at Breckside Park without appropriate references having been attained. This issue must be addressed, so as to ensure residents are safeguarded. Furthermore, the responsible person should ensure that an application for registration of a manager is made to the Commission, to ensure compliance with the Care Standards Act 2000. Arrangements should also be made to risk assess all safe working practices, to safeguard the health and safety of the people living in the home. 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. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents do not have access to up-to-date service information, to enable them to make an informed choice about the home. EVIDENCE: A ‘Statement of Purpose’ and ‘Service User Guide’ had been produced in a standard format to provide information on Breckside Park for the people who use the service and their representatives. A copy of the Service User Guide was displayed in the reception area of the home for visitors to view and the Statement of Purpose was stored in the office. The acting manager was recommended to explore the possibility of producing the document in alternative formats, to assist people to read and understand the information more easily. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 10 The acting manager was advised to also date and revise both documents, as some of the information was incorrect. For example, the documents contained the names of former managers and the contact details of the Commission for Social Care Inspection were incorrect. The acting manager reported that the people who use the service or their representatives were provided with terms and conditions of residency upon moving into the home. Files viewed as part of the case tracking process contained a contract. Advice was given for the contacts to also include the details of the room allocated to each resident and the person or organisation responsible for the payment of fees, to ensure the people who use the service are aware of their rights and obligations. The Annual Quality Assurance Assessment for the service detailed that policies were in place for referral and admission. The personal files of three permanent residents were viewed during the visit. Records confirmed that the needs of the people using the service were assessed. It was not possible to confirm whether two of the assessments viewed had been completed before people had moved into the home, as the assessments had not been dated. Furthermore, the information obtained was limited, as a tick box approach had been used to record dependency levels for a number of needs and some equality and diversity issues had not been considered. The acting manager reported that the format of pre-admission assessments had improved for new referrals. Copies of assessments and care plans from social workers had also been obtained for two of the three people case tracked, to enable the service to determine the needs of prospective residents and whether or not these could be met at the home. Standard 6 is a key standard to be assessed however the home does not provide intermediate care. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Medication policies and procedures are not robust. This does not protect the health and welfare of the people using the service. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) for the service detailed that the service had policies and procedures in place for ‘Individual Planning and Review’, the ‘Control, Storage, Disposal, Recording and Administration of Medicines’ and the ‘Values of Privacy, Dignity, Choice, Fulfilment, Rights and Independence.’ Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 12 Three resident’s care plan files were viewed as part of the inspection process. Each file contained a care plan, which contained appropriate information on the needs of the people using the service, action required and the expected outcomes and covered a range of areas including; mental, psychological and physical health, personal care, occupation and social needs, promoting safety and promoting communication. Supporting documentation including daily, personal care and weight records were also in place. Care plans viewed had been kept under monthly review and had been signed by residents (where practicable). The manager was recommended to develop the care planning process as the text was mainly pre-populated and care plans viewed lacked a person-centred approach to care planning. Risk assessments had also been completed to outline hazards and risks to the welfare of the people using the service. Advice was given on how to further develop the risk assessment process as some risk assessments viewed had not been kept under regular review and did not adequately address potential risks. Discussion with residents and examination of health care records provided evidence that residents had accessed a range of health care practitioners including; doctors, dentists, district nurses and chiropodists, subject to the individual needs of the people using the service. At the time of the visit the main medication policy for the home could not be located. The acting manager reported that the policy had been removed by a former employee and agreed to ensure the information was replaced as a matter of priority for staff to reference. The acting manager was also recommended to obtain a copy of guidance issued by the Royal Pharmaceutical Society of Great Britain, to ensure best practice. A record of staff responsible for administering together with sample signatures was not on file. The acting manager reported that three staff, including herself, were responsible for the administration of medication and evidence of medication training was viewed for the three staff during the visit. None of the people using the service were responsible for administering their medication at the time of the visit. Personal files viewed did not contain any evidence that the wishes or consent of residents had been obtained in relation to the administration of medication and this should be addressed. A monitored dosage system was used at Breckside Park, which was dispensed by a local pharmacist. A sample of medication administration records were viewed during the visit and issues were noted regarding the standard of record keeping. For example, one resident had been prescribed an anti-biotic and the medication Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 13 administration record did not account for all of the medication. Likewise, another medication administration record viewed did not provide an explanation as to the reason why a prescribed medication had not been administered for five days. These issues must be addressed to account for prescribed medication and to safeguard the health of the people using the service. Similar issues were noted at the last inspection. On the day of the visit medication was correctly stored. Advice was given regarding the need to ensure the Controlled Drugs Cabinet was fixed to the wall using the correct method of fixing to ensure compliance with the Misuse of Drugs (Safe Custody) Regulations 2001. The acting manager was also recommended to monitor and record the temperature of the room where medication was stored. Staff spoken with during the visit demonstrated a satisfactory awareness of the value base of social care and were observed to offer appropriate support to the people using the service during the day. Likewise, feedback received from the people using the service confirmed their privacy was respected and that they were valued and treated with respect and dignity. Comments received from three residents included; “I have always been treated well”; “Very happy with care received from all staff” and “The carers are lovely.” Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the 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. The lifestyle experienced in the home is flexible and varied to enable the people using the service to have choice and control over their lives. EVIDENCE: Since the last visit the Acting Manager had produced a ‘Weekly Activity Schedule’ in a standard format, which was displayed on the notice board in the main foyer for the people using the service to view. The schedule detailed that a choice of activities was provided each day that was geared towards the physical, social and psychological needs of the people Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 15 using the service. Examples of activities include: skittles; balloon games; carpet bowls; domestic chores; art and craft; memory games; sing-a-long; hand massage; beauty session; film afternoons; sherry afternoon and spiritual activities etc. A ‘Residents participation record’ had also been developed which provided information on the range of activities provided and the participants. Examination of records confirmed that activities were provided on a regular basis however the majority of activities were based in-door. On the afternoon of the visit, some residents were supported to participate in a music session with input from a relative. The acting manager reported that residents were encouraged to access the local community independently, when they have the skills to do so and three residents had also been supported to Blackpool for a weekend break during August. Feedback received from residents and/ or their representatives via surveys and / or discussion confirmed the people using the service were generally satisfied with the range of activities provided however some residents reported that they would like the opportunity to go out on day trips. For example, one resident reported; “I’m not particularly interested in joining in activities but I would quite like to go on the occasional trip out.” The general atmosphere of the home remained warm and friendly. Staff were observed to communicate and engage with the residents in a positive manner and were seen to offer appropriate care and support to people when required. Residents spoken with confirmed they were able to follow their preferred routines, exercise choice and control over their lives and receive visits from family and friends at any reasonable time during the day. A four-week rolling menu had been developed in consultation with the people using the service, which offered a choice of meals. The acting manager confirmed that the service would cater for different health, cultural and / or dietary needs upon request. A recommendation was made to explore alternative options for the tea-time meals, as soup or sandwiches had been recorded frequently and to also specify the vegetables with each meal, as this information had not always been recorded. Meals were served in the home’s dining room at set times however the acting manager confirmed that alternative arrangements would be made to accommodate individual needs upon request. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 16 Staff were observed to be available to provide support and assistance to residents during meal times and the dinner time meal served during the visit appeared appetising and wholesome. Feedback received from residents via discussion and survey forms confirmed people were generally satisfied with the meals provided. Comments included; “The food is generally ok. Sometimes it can be a little bland”; “The meals are nicely prepared and there is always a choice and plenty to eat” and “I always enjoy the main meal of the day and have no complaints about the standard of catering.” Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. 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. Systems are in place to respond to complaints and to safeguard the welfare of vulnerable people. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) for the service detailed that a policy on ‘Concerns and Complaints’ had been developed. Information on the complaints procedure had been included in the Statement of Purpose and an outline of the complaints policy was available in the porch and in each resident’s room, to inform residents and visitors of how to complain. Feedback received from residents confirmed they had no complaints about the service and were confident that the acting manager and staff would listen and act upon any issues of concern. For example, a resident reported; “I am sure that if I made a complaint Lynn [the manager] would deal with the matter to my satisfaction.” The AQAA for Breckside Park detailed that two complaints had been received in the last 12 months however, examination of the complaints log for the service revealed that there had been four complaints. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 18 The first complaint was from a relative and concerned a personal care issue. The second complaint was from a resident and concerned the introduction of the smoke free legislation and the impact upon residents who wished to smoke. A further two complaints had also been received from another relative and this concerned the welfare of a resident who is no longer living at Breckside Park. One of the complaints made had been investigated as part of an adult protection strategy meeting and was unsubstantiated. All the complaints had been responded to by the acting manager to ensure issues of concern had been acted upon. Internal policies and procedures had been developed to provide guidance to staff on how to recognise and respond to suspicion or evidence of abuse and for Whistle blowing. At the time of the visit a copy of the City of Liverpool and Borough of Sefton – Safeguarding Adults Policy could not be located and the acting manager was advised to obtain another copy for reference. Records detailed that the majority of staff had completed training in the Protection of Vulnerable Adults from abuse and staff spoken with demonstrated awareness of the different categories of abuse and how to respond to suspicion or evidence of abuse. No progress had been made in undertaking an analysis of accidents and incidents as recommended at the last inspection. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 environment has received ongoing investment and this has resulted in the people using the service benefiting from a homely, comfortable and safe environment. EVIDENCE: Breckside Park accommodates 26 residents over 3 floors of accommodation. There are 2 lounges, a dining room, large conservatory and 26 single bedrooms, five of which have an en-suite toilet. There is a large well maintained and enclosed garden to the rear and further garden areas to the side and front of the premises. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 20 At the time of the visit the home did not have a handyperson who was responsible for general maintenance and repair. The registered person undertook minor maintenance work and contractors were hired to maintain the grounds and for major and specialised work as and when required. A ‘Building and Maintenance Action Plan’ for internal and external works for 2008 had been developed for Breckside Park, to ensure the environment continued to receive ongoing investment. Discussion with the acting manager and examination of the Annual Quality Assurance Assessment for the service revealed that Breckside Park had continued to receive ongoing maintenance and investment in the last 12 months. For example, all bedrooms had been refurbished and re-carpetted where necessary, a new bathroom (with adapted bath for the use of people who have difficulties with their mobility) and shower room had been installed and a new cinema screen had been purchased for a lounge. Furthermore, new carpets had been fitted to all communal hallways and floors and the front entrance had been redecorated. New furniture had also been bought for the dining room and two lounges. Residents confirmed that they felt the standard of the accommodation was improving and one person said “I’ve got new furniture in my bedroom. It’s lovely.” A tour of the premises was carried out which included all communal areas of the home. Overall, areas viewed appeared to be clean and reasonably wellmaintained. The registered person was advised to risk assess the floor covering installation throughout the premises, as the carpets were not appropriately fitted in some parts of the home. For example, the carpet had become detached from some gripper rods on a staircase and in a lounge and a doorplate was loose and raised in a corridor. The home has aids and adaptations for those residents with mobility needs. There is access to the front of the property via a ramp but there is then a step for access to the house. There is also ramped access at the rear of the home. On the day of the unannounced inspection, the home presented as clean, warm and comfortable environment. The laundry area was clean and well organised and the Annual Quality Assurance Assessment (AQAA) for the service detailed that a policy on communicable diseases and infection control was available for reference. The AQAA also confirmed that the majority of the staff team had completed training on the prevention of infection and management of infection control. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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. Recruitment practice is not sufficiently robust, to fully safeguard the welfare of the people using the service. EVIDENCE: At the time of the inspection, twenty-four people were living in the home. Examination of the rotas and discussion with the acting manager and staff confirmed the staffing levels in the home remained the same as at the last inspection. Three members of care staff were on duty through the day and evening and at night the premises was staffed with two waking night staff and a senior carer who undertakes sleep-in duties. Residents spoken with during the visit were generally complimentary of the staff team and confirmed staff were available when needed and that they received the care and support they required. Comments included; “The care staff are nice”; “The standard of care provided is good” and “I can’t fault the people who look after us.” Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 22 The Annual Quality Assurance Assessment (AQAA) for the Service detailed that a policy on recruitment and employment had been developed and that all the people who had worked in the home in the past 12 months had completed satisfactory pre-employment checks. The acting manager reported that four care staff had commenced employment in the home since the last inspection and the recruitment records for the four staff were viewed during the visit. A number of issues with references were noted. For example, one file contained two references, which were not dated and there was no record of the date the references had been received. Likewise, another file contained only one reference and there was no indication that the references had been verified. This fails to protect residents from abuse as highlighted at the previous inspection. Criminal Record Bureau checks and staff identification were in place for all new staff. At the time of the inspection, the home employed 11 day care and 5 night care staff. Documentary evidence was available to confirm that 8 (50 ) of the care staff had a National Vocational Qualification (NVQ) in Care at level 2 or above. The acting manager reported that a further two (12.5 ) staff had completed the award and were waiting to receive certificates and three (18.75 ) staff were working towards a NVQ at the time of the visit. Once all the staff have completed their qualifications and received documentary evidence, 13 (81.25 ) of the 16 care staff will be qualified to NVQ level 2 or above in Care. A training and development programme had not been developed as recommended at the last inspection and examination of training records revealed that new care staff had not been inducted in accordance with the Skills for Care – Common Induction Standards. This issue had also been noted at the last inspection. Individual records of training completed together with documentary evidence were available for each member of staff. Examination of records confirmed that staff had access to a range of training and development opportunities that were relevant to their roles i.e. Moving and Handling; Abuse; First Aid; Food Hygiene and Dementia etc. Some gaps in training were noted for example, Fire training. The acting manager confirmed that the outstanding training needs of staff were monitored and that action would be taken to ensure all staff completed the necessary training that was relevant to their role. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 23 Staff spoken with confirmed they had completed various training courses during their employment at Breckside Park. The acting manager was advised to develop a training plan and matrix and to continue to increase the range of training opportunities available to staff. This training should include raising awareness of equality and diversity issues, as staff spoken with lacked knowledge and understanding in this key area. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the service is in need of ongoing development and review, to ensure the home has effective quality assurance systems and is run in the best interests of the people using the service. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 25 EVIDENCE: Breckside Park did not have a manager who was registered with the Commission for Social Care Inspection and this is in breach of the Care Standards Act 2000. The registered person had appointed Linda Lyon as the acting manager of the service. Ms Lyon reported that she had acted as the manager since January 2007 and that since the last inspection she had completed a level 4 National Vocational Qualification (NVQ) in Health and Social Care. Ms Lyon reported that she was intending to apply to the Commission for registration as the manager and advice was given regarding the application process and the need to also complete a NVQ level 4 in Management. Examination of training records and certificates confirmed the acting manager had completed a range of training that was relevant to her role. Records detailed that the acting manager had completed: managing investigations; moving and handling; abuse; food hygiene; fire safety; first aid; medication; diabetes and oral health training since the last visit. Feedback received from the residents and staff team confirmed the acting manager was supportive and approachable. For example, a resident reported “Lynne [acting manager] is great” and an employee stated; “We have a very good manager now who is understanding and will support you in every way.” Minutes were available to confirm staff and resident meetings had been coordinated every four months and staff received formal supervision from their manager periodically. Prior to the inspection, the acting manager completed an Annual Quality Assurance Assessment for the service. All sections of the document were completed however there were areas were more supporting evidence would have been useful to illustrate what the service has done in the last year and how it is planning to improve. Since the last visit, a quality assurance audit system had been introduced in the service which outlined a range of environmental, health and safety, service records, care practice and personnel standards which were to be audited. Records showed that the system had commenced operation in approximately February 2008 and weekly, monthly and quarterly audits had been undertaken up to July 2008. From this month the system had lapsed and records had not been kept up-to-date. The acting manager reported that a ‘Stakeholder’ and ‘Resident / Relatives questionnaire’ had been distributed to the people using the service and their relatives in the past two months. Only eight were available on file and the results had not been summarised or published. Advice was given on how to Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 26 develop the questionnaire. An annual development plan had also been developed but this was not dated. The Annual Quality Assurance for the service detailed that a policy had been developed on the management of service users’ money, valuables and financial affairs. The acting manager reported that relatives supported most of the people using the service to look after their personal finances. At the time of the visit, the registered person and acting manager had been requested to administer personal money on behalf of some of the people using the service. A written record of financial transactions was maintained and receipts had been retained to account for expenditure. Balances checked were correct. The registered person was recommended to review the arrangements in place for one resident, in consultation with social services, as concern was noted regarding the welfare of the resident. The Annual Quality Assurance Assessment for the service detailed that Health and Safety policies and procedures were in place and that test and maintenance checks were undertaken periodically Fire records were checked during the inspection. A fire risk assessment was in place and records had been developed to provide evidence that the operation of the fire alarm system had been checked on a weekly basis. At the time of the visit, records were not in place to confirm the fire extinguishers and emergency lighting had been visually inspected or tested on a monthly basis and some gaps were noted for fire training for staff. Certificates were available to verify that the fire alarm system, emergency lighting and fire extinguishers had been serviced and the AQAA detailed that other equipment and services in the home had been routinely checked and serviced. No progress had been made in undertaking a risk assessment for safe working practices, to safeguard the health and safety of the people using the service. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 27 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 2 2 3 2 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 2 34 X 35 3 36 X 37 X 38 2 Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 28 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 OP9 Regulation 13 (2) Requirement Medication must be stored, administered and documented appropriately at all times so as to safeguard the health and well being of residents. [Previous timescale of 29/02/08 not met]. Staff must not commence employment without appropriate references having been attained, so as to ensure residents are safeguarded. [Previous timescale of 29/02/08 not met]. Timescale for action 17/09/08 2. OP28 19 (1) (b) 17/09/08 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 OP1 Good Practice Recommendations The statement of purpose and service user guide should be updated and produced in alternative formats to ensure DS0000025331.V362643.R01.S.doc Version 5.2 Page 29 Breckside Park Residential Home 2 OP2 3 OP3 4. OP7 5. OP7 6. 7. OP9 OP12 8. OP15 9. OP18 10. 11. OP19 OP30 12. 13. OP31 OP33 people have up-to-date and accessible information on the service. The terms and conditions of residency should be updated to include the room number allocated to each resident and the details of the person / organisation responsible for fees. This will help to clarify rights and responsibilities. Comprehensive assessments of need should be undertaken by trained staff, which are dated and include information on equality and diversity information. This will ensure a more holistic assessment of needs is undertaken. Care plans should be based upon a comprehensive assessment of needs and reflect a person-centred approach to care planning, to confirm the individual needs of the people using the service are taken into consideration as part of the care planning process. Risk assessments should be kept under review and clearly identify how potential areas of risk are to be managed. This will ensure the welfare of the people using the service is safeguarded. A medication policy should be developed and available for staff to reference, to ensure best practice in the recording, safekeeping, administration and disposal of medicines. Residents should be offered opportunities to be involved in a greater range of community based activities, to ensure the recreational needs and expectations of the people using the service are met. The menus should be updated in consultation with the people using the service, to ensure the vegetables at each mealtime are recorded and to explore alternative options for the tea-time meals. This will help people to fully understand the meals on offer and help to provide more variety and choice. A copy of the local authority safeguarding adults procedure should be obtained for staff to reference. This will help to clarify roles and responsibilities in safeguarding vulnerable adults from abuse. The carpet installation should be risk assessed to ensure any trip hazards are identified and addressed. A training and development programme should be developed and care staff should be inducted in accordance with the Skills for Care – Common Induction Standards, to ensure staff complete appropriate training for their roles. An application for the registration of a manager must be made to the Commission for Social Care Inspection, to ensure compliance with the Care Standards Act 2000 The quality assurance system for the home should be further developed, maintained and reviewed, to ensure the DS0000025331.V362643.R01.S.doc Version 5.2 Page 30 Breckside Park Residential Home 14. OP35 15. OP38 service is run in the best interests of the people using the service. The registered person should review the arrangements for the management of residents’ personal finances in consultation with other professionals, where there is concern regarding the welfare of the people using the service. This will help to safeguard the welfare of vulnerable people. Risk assessments should be completed for all safe working practices, to safeguard the health and safety of the people using the service. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection N W Regional Contact Team 3rd Floor Unit 1 Tustin Court Port Way Preston PR2 2YQ 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. Breckside Park Residential Home DS0000025331.V362643.R01.S.doc Version 5.2 Page 32 - 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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