Inspection on 06/11/09 for Breckside Park Residential Home

This inspection was carried out on 6th November 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Breckside Park Residential Home 17/09/08

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 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Breckside Park Residential Home 10 Breckside Park Anfield Liverpool Merseyside L6 4DL Lead Inspector Debbie Corcoran Key Unannounced Inspection 6th November 2009 09:30 DS0000025331.V378463.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Breckside Park Residential Home DS0000025331.V378463.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 Manager post vacant Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 26 Date of last inspection 17th September 2008 Brief Description of the Service: Breckside Park is a registered care home providing personal care for up to 26 people who are over 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 £330.00 per week. Breckside Park Residential Home DS0000025331.V378463.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 that the people using this service experience adequate quality outcomes. The visit to the home was not announced beforehand. During the visit the majority of the people living at the home were met and a number were spoken with either on a one to one basis or a small group basis. We sent surveys to people using the service and to members of staff before we carried out the inspection visit. Some of the information in these has been used to assist us in assessing the service and forming judgments about the quality of outcomes for people living at the home. A sample of records were looked at in relation to peoples care. We also looked at other records including medication administration records, staff files, staff training records and health and safety records. These help to show us how peoples health and wellbeing are being promoted and whether staff have the skills and training needed to support people appropriately. A tour of the home was carried out which included all areas. The manager returned a self assessment of the service prior to this visit. The self assessment enables the service provider to inform us of what they do well, where they have improved and where they can improve in the future. It also includes information on how they promote equality and diversity, how they seek the views of people living at the home and includes data on staffing and health and safety. The self assessment is referred to as an Annual Quality Assurance Assessment (AQAA). Some of the information in this has been used to inform the findings of the inspection and the reader can see information taken directly from this within the main body of the report. What the service does well: The home provides a relaxed, homely atmosphere for people to live in. Each of the people living at the home has a care plan and risk assessments are carried out in relation to their care needs and these include information on how to manage any identified risks. People living at the home feel well supported with their health care needs and are regularly supported to see a GP, Community Matron, dietician etc. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.2 Page 6 People have the opportunity to be involved in activities on a regular basis. People who live at the home are provided with their own bedroom and these are fitted with quality furnishings. People are encouraged to bring some of their own belongings into the home so as to personalise their rooms. The majority of staff have attained a relevant qualification. Staff are also trained in topics such as supporting people who have dementia care needs, safeguarding adults, fire safety, first aid, food hygiene, infection control and moving and transferring people safely. This level of training shows us that staff should be able to safeguard the health and wellbeing of people living at the home appropriately. Health and safety checks are carried out on a regular basis to safeguard the health and wellbeing of people living at the home, staff and visitors. What has improved since the last inspection? What they could do better: When a new person is referred to the home the manager should attain a copy of their assessment of needs from the referring agency prior to the person moving in. Where an assessment of needs is carried out by a member of staff from the home then they should be appropriately experienced and competent to carry out such an assessment. The home should not admit any new people without having a thorough and comprehensive assessment of their needs and being confident that the persons needs can be safely and effectively met at the home and within the homes categories of registration. Each of the people living at the home has a care plan. We found some care plans had not been updated to reflect changes in a persons needs. Not providing staff with accurate, up to date care plans can place people using the service at risk of not receiving the care and support they need. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.2 Page 7 Some medication practices are not in line with safe medication management and this needs to be addressed to safeguard the health and wellbeing of people living at the home. The quality assurance system must be developed to ensure it is objective and includes surveying the people using the service. The home has not had a manager who is registered with the Commission for a number of years. The provider must address this and ensure an application for registration of a manager is made. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 8 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 Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New people are admitted without an appropriately detailed assessment of their needs having been attained or carried out and this may mean that people are admitted whose needs cannot be safely and effectively met at the home. EVIDENCE: We looked at the statement of purpose and service user guide. These are documents which provide information on the services and facilities provided at Breckside Park. They include information on assessment of needs, meals, medical care, how to make a complaint, maintaining privacy and dignity, arrangements for social activities, how people are consulted with, fire and emergency arrangements. People who are thinking of moving into Breckside Park can use these in order to aid their decision. People told us in surveys that they received enough information about the home to help them decide if it was Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 10 the right place for them before they moved in and they had been given written information about the home terms and conditions of the service. When a new person is intending to move into the home then a senior member of staff carries out an assessment of their needs. This is aimed at ensuring that the persons assessed needs can be met at the home. We looked at the assessment information for two people using the service. We noted that some assessment and care planning information had been attained from the referring agency, for example Social Services, when this was appropriate. We found that the assessments carried out by the manager were very basic and the information did not reflect the needs of the person. We discussed concerns regarding this with the manager as this may mean that people are admitted whose needs cannot be made appropriately at the home and this may put the person concerned and other people living at the home at risk. This concern has been identified at past inspections and it is of concern that the assessment and admissions process continues to fail to safeguard people. We found that further assessments are carried out once the person has moved to the home. These are more comprehensive and we saw that they have been reviewed on a regular basis. People are given the opportunity to visit the home and spend some time there before deciding if it is the right place for them. This was confirmed during discussions with people living at the home. People living at the home are provided with a contract as to the terms and conditions of their residency. We did not look at the details of these on this occasion. The home does not provide intermediate care and therefore standard 6 was not assessed on this occasion. The statement of purpose and service user guide should be amended to reflect this. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are not updated to reflect the changing needs of the person and this means that peoples needs are not always clearly reflected in their care plan and this may compromise their health and wellbeing. Medication practices are not sufficiently managed to safeguard the health and well being of people living at the home. EVIDENCE: We case tracked three people using the service. By this we mean that we looked in more detail at their needs, the type of support they were receiving and their care plans. The care plans were found to include information on how to meet a persons needs in areas such as such as their mobility, personal care, nutrition, communication, mental health and safeguarding their wellbeing. We found that care plans were pre populated documents which were then adapted to the Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 12 person concerned. This results in the care plans not being individualized or person centred and we saw some examples whereby the information in the care plan was not correct as it did not relate to the individual. We also found that whilst care plans were being reviewed on a monthly basis and this was documented the actual care plans had not been updated to reflect the changes in a persons needs. For example a care plan dated 17/09/07 reflected that the person had no special dietary needs. However, after reading through review records and other information it was evident that the persons needs had changed to such an extent that they required blended meals and a food supplement. We could see that appropriate action had been taken to ensure the person had been weighed on a regular basis, had seen a dietician and their diet had been changed to accommodate their needs but this was not reflected in the persons care plan as written two years previous. Staff need to have access to up to date and accurate information on the needs of the people they support so as to ensure they are aware of the persons needs and how to meet these. We found that assessments had been carried out into aspects of a persons support such as their moving and handling needs, physical health care needs, nutritional needs and risks associated with their needs. We looked at records which told us when a person had been seen by a health professional for example, GP, nurse, optician and these showed us that people are being well supported to maintain their health. We found that where a person may have started to become nutritionally compromised then they had been referred to a dietician or where they required support with mobility they had been referred for occupational therapy or physiotherapy as appropriate to their needs. There was no evidence that people are consulted with on their care plan or supported to be included in developing their care plan. This should be addressed as it is important to ensure people have been included in deciding their care and agreeing to how their needs will be met. Most people living at the home were observed to look well supported with their personal care and comfort. For example people looked well presented and were wearing appropriate foot wear, spectacles etc. However, we did note that a small number of people were presented as not well supported with their personal care and this was commented on by other people in the home. This may compromise the dignity and respect of the people concerned and should be addressed by the manager. People living at the home were asked if they felt that their privacy and dignity was upheld when being supported with their personal care. All responses to this indicated that they did. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 13 The manager told us in the self assessment of the service (AQAA) that they do the following to ensure equality and diversity is incorporated into the service An equal opportunities policy is in place, we also ensure this is instilled into all staff members so they are able to understand and identify what service users requirements may be ie religious beliefs and that privacy and dignity is maintained at all times. We looked at how medication is being managed. Medication is administered by senior members of staff who have been provided with training in this. We looked at a sample of medication and we found that medication was not being stored or administered appropriately. Two random inspection visits have been carried out by a pharmacist inspector since the last key inspection and these have identified some areas of concern regarding medication practices and the home were given requirements and a number of recommendations to address these. During this visit we found a number of further examples where medication practices were not appropriate and fail to safeguard the people living at the home. These were; One type of medication (tablets) were found in the medication cabinet with no label on and there were two loose tablets in the bottom of the box. One type of medication had a hand written note only on it. Eye ointment had been opened but was not dated as to when opened. Medication was misplaced in the medication cabinet and was found under the names of other people. Where medication administration records had been hand written we saw some examples where these entries had not been signed by another member of staff and we saw an example whereby they had been double signed but one of the entries was incorrect. We saw one entry on a medication administration record whereby a line had been put through an entry but there was no information as to why and when staff were asked to explain this they were unable to unable to. Staff therefore did not know if the medication was still prescribed or whether or not it needed to be administered. We saw a number of examples whereby medication had been signed for as administered but the medication in stock did not balance with these records. This indicated that staff had signed as having administered particular medications when they had not. This also indicates that the auditing system which the manager has introduced is not effective in ensuring safe medication practices. It also indicates that the managers recently introduced assessment of staff competence in administering medication is not effective. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are encouraged to partake in activities and to use the local community. The service promotes a flexible lifestyle which enables people to maintain choice and control over their lives. EVIDENCE: In order to assess the level and variety of activities available to people we spoke with people living at the home and we viewed records which contained details of what activities had taken place over the previous couple of weeks. These showed us that people are supported to be involved in activities on a regular basis. These are facilitated by members of the care staff team and include activities such as watching films, quiz, balloon games, exercises, dominoes, reading papers and an entertainer visits the home occasionally. There have been two trips out recently one to Aintree Racecourse and one to Blackpool illuminations. Both were reported to have been enjoyed by people living at the home. People told us in surveys that they are always or usually activities to take part in. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 15 A number of people will choice not be included in group activities and their choice to do this or spend time on their own is clearly respected. During discussions with people living at the home they were asked about the choice and control they have over their daily lives. People confirmed that they choose their own daily routine as to when to get up, choice of meals throughout the day, support with personal care such as bathing. People were observed to be spending time in their room or in the lounge and some people were observed to be involved in activities. People living at the home have the opportunity to attend resident meetings on a regular basis. Minutes are taken of these meetings and these showed us that there have been four such meeting this year. These meetings provide people with a forum to discuss the service and to contribute to decision making at the home. People living at the home were asked about the quality and choice of meals provided. Whilst most of the comments made werent negative they werent positive either and the most common response about the meals was theyre alright. People told us in surveys that they usually or sometimes enjoy the meals at the home. The manager said that people had been consulted with on meals and the four week menu was devised based on their feedback. On the day of the visit the main meal was being served at lunchtime. There were two choices on offer and people were being asked what they would like as the meal was being served. We noted that people who have a blended meal were not offered an alternative and we also noted that their meal was blended into one. Good practice would be to blend and present each type of food separately so that people can have a variety of tastes and a more enjoyable mealtime experience. The evening meal was sandwiches and soup, alternatives to this are basic hot foods. The manager should review the menu, this is to ensure it is in line with the needs and wishes of people living at the home, and to ensure it is nutritionally balanced. We noted that although clean the kitchen would benefit from some refurbishment. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies, procedures and practices are in place for dealing with complaints and for aiming to protect people living at the home from abuse or neglect. EVIDENCE: The home has a complaints policy and procedure. People who gave us feedback in surveys told us that they would let staff know if they were not happy about something and that staff would then address their concerns and that they knew how to make a formal complaint. Information on how to make a complaint is provided to people in the service user guide. The manager reported that there have been no complaints made to the home since the last key inspection. We have received one complaint since the last key inspection and this initiated two random pharmacy inspections by a pharmacist from the Commission and the provider also investigated some aspects of the complaint and reported back to us on their findings. Reports on the random inspections are available from the Commission upon request. An adult protection policy and procedure is in place. This outlines responsibilities for responding to an allegation of abuse and any subsequent investigations. Staff recruitment procedures include a check against the Protection of Vulnerable Adults register and attaining a criminal records bureau check for new members off staff. Staff have been provided with adult Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 17 protection training. During discussions with the manager she was able to explain what course of action she would take in the event of an allegation of abuse and was clear in her responsibilities to report safeguarding. We looked at accident records. These did not show any particular issues for concern. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment receives ongoing investment and this has resulted in the people being provided with a homely, comfortable and safe environment. EVIDENCE: Breckside Park is a large detached house set in its own grounds. The home is located in the Anfield Area of Liverpool. Accommodation is provided over three floors and there is a passenger lift for people who require it. Upon arrival at the home people seem to be relaxed and they were seen to be following their own routine. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 19 The home is registered to provide care to 26 people. Each person living at the home is provided with their own room. This does not mean that people who wanted to share a bedroom would not be able to. On the day of the inspection there were 26 people living at the home. We carried out a tour of the home and this covered all communal areas and a sample of bedrooms. We found evidence that there has been quite a lot of refurbishment of the home, particularly to bedrooms. We found bedrooms to be well presented and each room has a vanity unit with fitted sink and new fixtures and fittings. The home has an adapted bath for people who have difficulty getting into a bath and there is also a walk in shower on the first floor. The home has two main lounges and these are presented as homely and comfortable. A conservatory is located at the rear of the home and this is used as a smoking area for people living at the home. We recommend the manager carries out a risk assessment regarding access to the basement. Any necessary works as a result of this should be carried out in line with fire safety regulations. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are supported by qualified and well trained staff. EVIDENCE: We looked at how many staff were on duty when we arrived at the home and we checked staff rosters to confirm what usual staffing levels are. At time of the visit there were twenty six people living at the home and four staff on duty including the manager. There has been only one new member of staff to the home since the last key inspection. We looked at their file to assess recruitment and selection practices and ensure these were in line with protecting people. This showed that pre employment checks had been carried out prior to starting the new member of staff. These practices aim to safeguard people living at the home. Whilst checks had been carried out we would recommend some improvements to practice in the recruitment and selection of staff. These include; the manager should review and update the application forms and reference requests in use and applicants should be required to provide the necessary details of their referees including the capacity in which they are known to the applicant. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 21 The manager told us in the providers self assessment of the service (AQAA) that 16 out of the 17 care staff have attained a relevant National Vocational Qualification (N.V.Q) in Health and Social Care. The minimum ratio of 50 percent trained staff has therefore been achieved and exceeded. The manager provided us with a training matrix whereby we could see what training individual members of staff have had and what training the staff team as a whole have had. We also looked at staff files in order to gain information on the level and type of training that staff have been provided with. These showed us that staff have regular training in topics such as moving and handling, first aid, fire safety, food hygiene, infection control, medication, diabetes and supporting people who have dementia. This level of staff training aims to ensure that staff have the appropriate skills and knowledge to carry out their role effectively and to safeguard the health and wellbeing of people using the service and of care staff. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some aspects of the service require development by the manager in order to demonstrate the health, safety and well being of the people using the service. EVIDENCE: The home does have a designated manager who has attained a relevant qualification. However, the home has not had a registered manager for a number of years. The provide must ensure an application for manager is made to the Commission. As identified in the Choice of Home and Health and Personal Care sections of this report there are improvements needed in relation to the admissions Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 23 procedure, care planning and medication practices. These are required in order to safeguard the health, safety and wellbeing of people living at the home. The manager has introduced a system for quality assurance. This involves the manager carrying out checks on the practices at the home. Whilst this may form part of a quality assurance process we would recommend that a more impartial process is employed as the current system only involves the manager auditing her own practices. People using the service have not been surveyed on their views of the service and this should form part of a quality assurance process. The process for supporting people using the service with managing their personal allowances was looked at for a sample of people. This was presented as a straight forward and accountable process. We did not look at how people are supported with any other income or expenditure on this occasion. We noted from staff records that some staff are provided with supervision meetings on a regular basis but we noted that one member of staff had been in post for approximately 12 months and had received only one supervision. The manager should ensure that staff have equal access to supervision and that all members of the staff team are provided with regular supervision. Team meetings take place on a regular basis. Supervisions and team meetings are important as they provide an opportunity for staff to communicate important information about the service, about the people using the service and to explore their development as workers. Health and safety policies, procedures and practice are in place to safeguard the well being of people living at the home, staff and visitors. A sample of fire safety and health and safety checks were looked at. These were found to be up to date. Safety certificates were viewed and those seen were up to date. Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 24 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 2 X 1 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 25 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 OP3 Regulation 14 Requirement Comprehensive assessments of need should be undertaken when a new person is referred to the service. These must be undertaken by appropriately trained and competent staff. This is to ensure that only people whose needs can be met effectively and safely are admitted to the home and to ensure the home meets the conditions of registration. 2. OP7 15 Care plans must include up to 06/01/10 date and accurate information on how to meet the needs of the person in all aspects of their health and wellbeing. To promote the persons health and wellbeing and ensure staff are aware of what actions they need to take to meet the persons needs. 3. OP9 13(2) Medication must be stored, administered and documented appropriately at all times so as DS0000025331.V378463.R01.S.doc Timescale for action 06/12/09 06/12/09 Breckside Park Residential Home Version 5.3 Page 26 to safeguard the health and well being of residents. [Previous timescales of 29/02/08 and 30/09/09 and 06/03/09 not met]. 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 reviewed and updated to ensure they provide accurate information as to the services and facilities provided. The provider should also consider producing these in alternative formats to ensure people have up-to-date and accessible information on the service. Care plans should reflect a person-centred approach to demonstrate peoples individual needs are taken into consideration as part of the care planning process. People using the service should be included in developing their care plan. They should also be given the opportunity to sign their care plan as having been consulted on it and in agreement with it. The menus should be updated in consultation with the people using the service. This is to explore alternative options for the tea-time meals, to ensure people who require a blended meal have an alternative option for this and to ensure a nutritionally balanced diet is provided. The manager should carry out a risk assessment regarding access to the basement and ensure any necessary works are carried out as identified and as in line with fire safety regulations. The manager should review some of the staff recruitment and selection procedures to ensure they are in line with best practice. DS0000025331.V378463.R01.S.doc Version 5.3 Page 27 2. OP7 3. OP7 4. OP15 5. OP19 6. OP29 Breckside Park Residential Home 7. OP33 The quality assurance system must be developed to ensure it is objective and includes surveying the people using the service. This is to demonstrate that the provider is monitoring the quality of the service and checking on outcomes for people using the service. Staff should have equality of opportunity to supervision meetings and the manager should aim to ensure all staff have regular supervision meetings. 8. OP36 Breckside Park Residential Home DS0000025331.V378463.R01.S.doc Version 5.3 Page 28 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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