Inspection on 24/08/06 for Brenalwood Care Home

This inspection was carried out on 24th August 2006.

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

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

Other inspections for this house

Brenalwood Care Home 11/06/08

Brenalwood Care Home 20/06/07

Brenalwood Care Home 14/12/05

Brenalwood Care Home 21/09/05

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

CARE HOMES FOR OLDER PEOPLE Brenalwood Care Home Hall Lane Walton On Naze Essex CO14 8HN Lead Inspector Ray Burwood. Draft Unannounced Inspection 24th August 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brenalwood Care Home Address Hall Lane Walton On Naze Essex CO14 8HN 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) 01255 675632 01255 679245 Brenalwood@btconnect.com R.W. Care Homes Ltd Vacant Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 38 persons) 14th December 2005 Date of last inspection Brief Description of the Service: Brenalwood is a home providing care and accommodation for 38 individuals over the age of 65 who have dementia. The premises consist of a large detached property, offering accommodation on two floors, with a passenger lift to the first floor. There are three double rooms and thirty-two single rooms, all rooms offering en suite facilities. The home provides a range of communal areas available for the use of all service users and a quiet room for visitors. The home is situated within walking distance of all the local amenities of Walton-on-the-Naze. Adequate parking spaces are provided to the side of the property. Current fees charged range from £367:15 to £600:00. Information about the service is made available through leaflets, a Statement of Purpose, and a Service User’s Guide stating the services provided at Brenalwood. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 23rd August 2006 with the assistance of the Acting Manager, the Registered Individual, Resident’s and Staff, my thanks to them all. The Lead Inspector was supported by his Regulation Manager during the early part of the site visit. The inspection involved looking at records, documents, and talking to staff. Additional feedback was received from staff and service users who had completed questionnaires prior to the inspection date. Feedback and interviews with service users and staff were positive about the standard of care, support, and the commitment of the management team. One residents’ relative said the home provided reassurance and good care. Another couple said there had been many changes for the good in the home, both physically and from an organisational point of view. Most records and documents were to hand at the inspection, those not accessible were requested to be submitted to the Commission. A total of 22 standards were inspected with 17 of the standards being met. 5 standards were partially met. At the end of the site visit, the inspection was discussed with the Acting Manager and advice and guidance was given regarding the findings. Discussions also included the future management of the home. What the service does well: The home provides a good standard of care and support in a well maintained and furnished environment for people suffering from different degrees of dementia. Residents are offered a stimulating and varied programme of events dependent upon their wishes, abilities, and assessed needs. Relatives and friends are made welcome. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 6 The home provides good meals with choices available from a seasonal menu. The current management of the home and input from the Registered Individual and Registered Manager from another home has ensured that resident’s and staff needs are maintained during a period of change of managers. The home maintains a good relationship with other professionals in the community, including hospital and primary care services. What has improved since the last inspection? What they could do better: The home’s quality control system requires further development to ensure that there is a clear plan to ensure that the service improves. Adequate bathing facilities should exist that are suitable to ensure that residents’ disability needs are met in a safe manner. A register specifically to record the administration of controlled drugs must be in place. The registered person must ensure that all new resident’s assessed risks are documented and included in their plan of care. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 7 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. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 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 Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home manages the admission process well, thus helping ensure that the individual assessed needs and appropriate admissions take place. EVIDENCE: From the evidence contained in the resident’s care files inspected a full assessments of needs had been completed prior to admission to the home. An additional summary of needs and care plans (health and social services) was also contained within the files inspected and contributed to generating a plan of care. The Acting Manager advised that there is an additional assessment of needs carried out during the trial period to ensure that they can be met, and the placement is appropriate to the needs and safety of other residents. The home does not offer intermediate care. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. 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. Residents’ are looked after well in respect of their health and personal care needs. Further attention needs to be given to information gained from the assessment process regarding risk. The home’s medication policy and procedures ensures the protection and wellbeing of residents, however, appropriate records of the administration of controlled drugs are not being kept. EVIDENCE: Care plans examined during the site visit were generally well presented and included sufficient information to enable care staff to carry out their duties. Care plans of new residents did not include risk assessments, although risks had been identified initially prior to the admissions taking place. In some cases, plans had been reviewed on a monthly basis but a record of reviews was not evident at the site visit. Plans were in place to include a more comprehensive system to review outcomes and records, together with a review Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 11 of the care planning process. Further weekly audits are being introduced in respect of care plans, daily logs, issues arising; e.g. falls, at risk etc. and a weekly audit of accidents and actions taken. A new log was being introduced to ensure the visits carried out by professional are recorded in each individual residents file. The quality of record keeping does not reflect the actual quality of care being given, which residents and relatives spoken with said was good. The health care needs of residents were discussed with care staff who had a good knowledge of the procedures relating to personal care, and the involvement of other professionals, either visiting the home or services accessed in the community. The home makes use of hospital services and community psychiatric nursing services to support residents who are suffering from depression or anxiety. The home’s medication policies and procedures were appropriate to individual residents needs, with records in place. At the time of the site visit there was no evidence of a Controlled Drugs Register although one resident was taking such a drug. The Acting manager was aware of the need to ensure a separate register was in place, and was awaiting the delivery of a new one. Senior staff are responsible for the administration of medication, and had undertaken the appropriate training. Further training was planned for the Acting Manager and seniors in the ordering and safe disposal of medications. Observations carried out during the site visit showed that staff had a good awareness of how to protect resident’s privacy and dignity. Residents and family members spoken with commented on how well their relatives and spouses were looked after and supported by staff. One resident spoke of the exercise class she attended (floor aerobics) and the laughs they had. Until recently she had been ill but she was looking forward to rejoining the group again. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. 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. Residents are supported by the home in exercising choice and control over their lives through contact with the community and visitors to the home. The meals prepared are good, offering both choice and variety. The special dietary needs of residents are catered for on an individual basis. EVIDENCE: Staff currently undertake activities with residents individually and as a group, with trips out to the promenade and a weekly visit to the local garden centre for coffee, and a browse. Some residents who are more independent are able to access local resources with assistance from either staff or relatives and friends. Activities programmes were prominently sited to inform residents what was available during the week and any special occasions taking place. During the site visit there was a continual stream of visitors to the home. This allowed the inspector to discuss with them their views relating to all aspects of the service provided. Overall, visitors were complimentary about the care and support offered by staff, and how the home had changed for the better. One Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 13 gentleman spoken with was concerned that his father had to enter residential care, how he would settle in, and would he receive a good standard of care. He commented on how his concerns were dispelled and the care of his father is excellent. Resident’s, who found it difficult to make informed choices, were supported by relatives and friends, some resident’s had their finances dealt with by solicitors employed by their families. Information for residents and families about advocacy services is made available through literature displayed on the resident’s notice board and included in the Service Users Guide. A number of people living in the home were spoken to regarding the food provided and the choices available. All those spoken with were complimentary about the food presented and the flexibility of arrangements. Menus were inspected and found to be balanced, interesting and flexible to accommodate individual preferences. A tour of the kitchen was undertaken and records found to be in place and correct. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. 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. Arrangements for dealing with complaints, together with appropriate policies and procedures, help ensure the protection of residents. EVIDENCE: Both standards relating to Complaints and Protection were met at the home’s last inspection visit, dated the 14/12/05. Appropriate policies and procedures were in place and no complaints have been received by the home since this date. Refresher training in Adult Abuse has been undertaken by most of the care staff, or planned for those staff that had not completed their probationary period. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21 and 26. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents live in safe, warm well decorated and furnished home that is regularly maintained inside and outside to a high standard. Bathing facilities are in sufficient numbers but are not accessible to meet residents’ needs. The home has systems in place to control the spread of infection in accordance with published professional guidance. EVIDENCE: A tour of the premises showed that the home is well maintained and suited to residents’ needs. The premises are decorated and furnished to help ensure that people with dementia are able to recognise areas and get about safely. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 16 An additional two single bedrooms have been created on the first floor since the home’s last inspection visit. Both rooms were found to be airy, bright and provide good quality accommodation, one of the rooms was occupied on the day of the site visit. A quiet area for visitors to use and a hairdressing salon for residents were provided by the home. Toilet, washing, and bathing facilities were found to be adequate in numbers and were provided in close proximity of bedrooms and communal areas. However, although there were adequate bathing facilities, some of the bathrooms were out of use because of difficulties with manoeuvring disability equipment safely. One ground floor bathroom required a bath side panel fitting that could accommodate a hoist. The Acting Manager was reminded that there should be a ratio of one assisted bath/shower to eight residents available with adequate disability aids to meet residents’ needs. A new alarm call system has been installed with an accessible alarm facility provided in all rooms. Laundry facilities provided were clean, hygienic and were used mainly for the residents’ personal clothing. Items such as bedding were contracted out to a private company. The home does not have sluicing facilities but has provided the Commission for Social Care Inspection (CSCSI) with a sluicing rationale that outlines the procedures should a resident need to use a commode. Staff are trained in infection control and are aware of the Universal Hygiene Rules. Currently, all bedrooms have en-suite facilities. Toilet management programmes and protocols are in place ensuring the dignity of resident’s are maintained, should they need to use a commode during the night. The Acting Manager was advised to incorporate this information in the home’s Infection Control Policy and Procedures. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Resident’s are supported by trained staff that are in sufficient numbers to meet their assessed needs. The home operates a robust recruitment process to help protect residents from abuse. EVIDENCE: Staffing levels in the home were sufficient to meet the needs of residents with the flexibility of staff hours to provide cover at busy periods. The Department of Health ‘Residential Forum’ was used for guidance to assess the required staffing levels. The Acting Manager confirmed that additional domestic staff would be employed to cover weekend cleaning duties. The files of three members of staff were sampled and examined. All files contained the information required in respect of persons working at a care home. Outstanding CRB checks not in place at the home’s last inspection for people coming from abroad have now been completed. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 18 A total of eighteen care staff are employed in the home with six trained to National Vocational Qualifications (NVQ) Levels 2 or above (33 ). Members of staff spoken with confirmed that they had received the appropriate training to enable them to carry out the assessed care needs of residents, but felt further training relating to later stage dementia would be beneficial to them. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The present quality assurance system does not fully ensure that the home is run in the best interest of residents. Resident’s and staff are supported by an Acting Manager who has developed her skills and provides a good management approach in the home. Safe working practices in the home promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The home’s Acting Manager is currently coming towards the end of her trial period and will consider her position regarding the vacant Registered Managers Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 20 post. The Registered Individual and the Registered Manager of another home owned by R W Care Homes have supported her through her trial period. Relatives and staff spoken with said there had been noticeable changes to the running of the home since the Acting Manager commenced her new role. Due to different degrees of dementia, residents are unable to control their own finances, and are either supported by their families, or have a solicitor to manage their affairs. The home has a policy relating to residents’ property and money. Residents’ allowances are kept in the office safe together with receipts of expenditures. Lockable facilities are provided in residents’ rooms for personal items. The home’s quality assurance system continues to be developed, with procedures in place to survey external agencies, residents, their families, and staff. The Registered Individual explained that her Personal Assistant had experience of quality assurance systems, this experience could be transferred to care situations, and she would be involved in processing survey results and the production of a report. The report would be made available when published to current and prospective residents, their representatives and other interested parties, including the Commission for Social Care Inspection. The Registered Individual said that a quarterly audit report was to be considered for the future. Records relating to the health, safety and welfare of residents and staff were inspected and found to be correct. Staff spoken with confirmed that they had completed health and safety training in safe working practices. Weekly audit sheets relating to the premises and health and safety checks were in place, together with weekly accident audit reports that are used to track incidents and possible patterns occurring. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 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 3 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 (1) Requirement Timescale for action 30/11/06 2 OP9 17 (1)(a)(b) Schedule 3 (3)(i) 23 (j) 3 OP21 4 OP31 8(1)(a)(b) (i) The registered person must ensure that residents’ care plans contain all of their assessed needs, in particular assessments of risk. The registered person must 30/11/06 ensure that appropriate records are kept in a separate register, of residents who are prescribed a controlled drug. The registered person must 30/11/06 ensure that there are sufficient numbers of baths/showers fitted with a regulated supply of hot water that are accessible, particularly for hoists. The Registered Individual must 31/12/06 appoint a person to manage the home. (Previous timescale of 31/03/06 not met). The registered person must ensure that information obtained through the home’s quality assurance system is collated into a report, and is made available to stakeholders and the Commission for Social Care Inspection (CSCI), DS0000062892.V309641.R01.S.doc 5 OP33 24(2) 30/11/06 Brenalwood Care Home Version 5.2 Page 23 (Previous timescale of 31/03/06 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 OP28 Good Practice Recommendations The registered should ensure that 50 of staff are qualified to a minimum of NVQ Level 2. Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brenalwood Care Home DS0000062892.V309641.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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