Inspection on 19/12/05 for Brenan House

This inspection was carried out on 19th December 2005.

CSCI 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 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

Brenan House 24/04/07

Brenan House 10/07/06

Brenan House 19/09/05

Brenan House 09/02/05

Brenan House 22/09/04

Brenan House 17/02/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Brenan House 21 Vale House Ramsgate Kent CT11 9DE Lead Inspector Sandra Crosby Unannounced Inspection 19th December 2005 09:00 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 Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 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. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brenan House Address 21 Vale House Ramsgate Kent CT11 9DE 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) 01843 582837 Mr David Barrie Spicer Sandra Caroline Spicer Vacant Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. The registered manager: has at least 2 years` experience in a senior management capacity in the managing of a relevant care setting within the past five years; and [by 2005], has a qualification, at level 4 NVQ, in management and care or equivalent; or where nursing care is provided by the home (ie nursing home), is a first level registered nurse and has a relevant management qualification [by 2005]. 19th September 2005 Date of last inspection Brief Description of the Service: The home is a large old building situated around an attractive tree lined square, close to the local shops and amenities. The home is laid out over several floors and has a shaft lift to all the floors providing accommodation to Service Users. Recently the Registered Providers have started to install en-suite facilities in some bedrooms. The top floor contains a private flat. There is a paved courtyard to the rear of the building. The home provides care for older persons and has started to develop a range of activities and entertainment. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes unannounced inspection. One Inspector conducted the inspection, and the duration of the inspection was four hours over one day. The home representative was one of the Registered Providers. Additional time was spent in planning the inspection and report writing. The focus of the unannounced inspection was to check on compliance with the requirements and recommendation made in the announced inspection report dated 19 and 20 September 2005. The atmosphere of the home was welcoming, calm and relaxed, and the home was clean and orderly at the time of the inspection visit. What the service does well: The home provides a welcoming homely environment. The service users and relatives appreciate how the staff are kind and caring. A variety of activities complimentary therapist. are provided including regular visits from a The cook at the home bakes cakes on a regular basis, and at the time of the inspection visit was preparing a range of party foods to be served that evening following the carol service. The ethos of the home is about providing a good quality of life for those who live at the home and this is reflected in the approach taken with providing care. The patio garden has been made into a pleasant environment with plants and vegetables. The building is well maintained with the Registered Providers continuing to look at improving the environment. What has improved since the last inspection? Re-decoration and improvement to the fabric of the building is ongoing. POVA First and CRB checks are being appropriately undertaken. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 The statement of purpose does not provide up to date information to enable prospective service users to make an informed decision. The contract/terms and conditions does not specify the services provided. Prospective Service Users are assessed but some are admitted outside of the registration of the home compromising the ability to meet the Service Users needs. EVIDENCE: Standards 3 and 5 were judged as standard met at the announced inspection visit dated 19 and 20 September 2005 and Standards 1,2, and 4 were judged as nearly met at that time. The judgements made at that visit remain the same at this inspection visit. The Registered Provider confirmed that to date the amendments to the Statement of Purpose and Service User Guide requested at the announced inspection visit in September 2005 had not been made, however she agreed to do this in the New Year. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 9 The Registered Provider also said that the terms and conditions between the Registered Provider and Service User had not been amended to include details of the services provided for the fee, but this would be completed in the New Year. As the pre-inspection questionnaire for the announced inspection visit confirmed that a number of service user have dementia and the home is not registered to for this category, the Registered Provider said that they would be applying for a variation of registered category for those Service Users that did not currently fall within the registered category of the home. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 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): 7,8,9,10 The care planning system does not adequately provide staff with the information they need to satisfactorily meet service users needs. Medicines are not being handled or managed effectively and that this could potentially place service users at risk. EVIDENCE: Standard 10 was judged as standard met at the announced inspection visit dated 19 and 20 September 2005 and Standards 7 and 8 were judged as nearly met and Standard 9 was judged as not met at that time. The judgements made at that visit remain the same at this inspection visit. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 11 One Service User Plan was examined, and it was seen that changes had not as yet been made to the system in place. There was no evidence that the regular reviews were up to date, and information was not seen in relation to skin integrity and nutritional assessments. Following discussion it was agreed that the home would no longer use the weight book and the communication book as all information in relation to Service Users should be recorded in the Service User Plans. It was also discussed that the amount of paperwork currently seen the Service User Plans could be reduced, and it was suggested that in the New Year the home could trial a couple of Service User Plans in a revised format before implementing the system for all of the Service Users. An audit of medication was conducted and errors were found in the recording of medications and discussed with the Registered Provider. She agreed to address these issues. The Registered Provider stated that the company providing the medications system were booked to visit the home in January 2006, to carry out an audit of medications kept in the home. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 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): 12,13,14,15 The programme of activities satisfies the wishes of the service users. A balanced diet is provided. Relatives are made welcome and are encouraged to visit. EVIDENCE: Standards 3 and 5 were judged as standard met at the announced inspection visit dated 19 and 20 September 2005 and Standards 1,2, and 4 were judged as nearly met at that time. The judgements made at that visit remain the same at this inspection visit. The home offers a variety of activities both within the home and activities outside the home. These include trips to the theatre, a trained complimentary therapist visiting on a regular basis and the usual range of activities that includes, gentle exercise, quizzes, sing-a-longs and activities in the gardens of the home. One service user is supported to enjoy their interest in gardening and although the garden is a large patio area this has been transformed with containers into a beautiful area. A small selection of fresh vegetables are now grown in the garden and then used by the home. The meals provided include hot choices. The cook bakes on a daily basis. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 13 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 There is a failure to formally acknowledge verbal complaints and to handle complaints objectively. EVIDENCE: Standard 16 was judged as standard nearly met at the announced inspection visit dated 19 and 20 September 2005 and Standards 17, and 18 were not inspected at that time. The judgements made at that visit remain the same at this inspection visit. Although the Registered Provider discussed a recent compliant issue, and the action taken to address the issue, there had been no written record made in relation to this. It was agreed that all complaints would in future time be recorded appropriately. Although Standard 18 was not fully inspected and no judgement made at this inspection visit, the Registered Provider discussed an issue that involved financial problems between Service User and family member, and it was indicated that appropriate action to involve other professionals had been taken by the home. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 14 Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 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): 19,20,21,22,23,24,25,26 The building is well maintained providing a homely environment for service users. EVIDENCE: Standards 19 to 26 were judged as standard met at the announced inspection visit dated 19 and 20 September 2005. The judgements made at that visit remain the same at this inspection visit. The Inspector was shown some areas of the home and these included the lounge on the first floor, currently decorated with Christmas decorations, the bathroom with the nearly fitted assisted bath, the shower room that also now had hairdressing facilities installed and the block of toilets that had been altered to provide more privacy. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 16 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): 27,28,29,30 Care staff are provided in sufficient numbers to meet the needs of the service users for most of the time. Recruitment procedures are improving and nearly meet the Standard thereby aiming to ensure the safety and welfare of the service users. Staff are attending training courses but they are not implementing the knowledge gained through training. EVIDENCE: Standard 27 was judged as standard met at the announced inspection visit dated 19 and 20 September 2005 and Standards 28 and 30 were judged as nearly met, and Standard 29 was judged as not met at that time. The judgements made at that visit remain the same at this inspection visit, except for Standards 27 and 29 that were judged as standard nearly met at this visit. The staff rota was seen, and the Registered Provided agreed to ensure that all staff members were on the staff rota including the hours that she herself worked. It was stated that staff had been taken on to cover laundry duties. It was seen overall that there are sufficient staff on duty for most of the time to meet the current needs of Service Users, however it was discussed that at some teatime periods there would only be one staff member on duty as the other care staff member would be providing the tea. The Registered Provider agreed to address this issue. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 17 From the staff files seen, it is indicated that the home is applying for POVA First checks and CRB checks. The home needs to ensure that all references are followed up, and placed on file. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 18 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): 31,32,33,36,37,38 The registered provider has the knowledge and skills to manage the home. The registered provider has a vision for the home but needs to develop their management style. There is no quality monitoring systems. EVIDENCE: Standard 31 was judged as standard met at the announced inspection visit dated 19 and 20 September 2005 and Standards 32,37, and 38 were judged as nearly met, and Standards 33 and 36 were judged as not met, and Standards 34 and 35 were not inspected at that time, except for Standards 33 and 36 that were judged as standard nearly met at this visit. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 19 The Registered Provider has recently completed the registered managers award. The welfare of the service users has been the priority of the registered provider however this needs to be taken further in the management of the home. Currently there is no form of auditing conducted to monitor the quality of practice or for an annual quality monitoring system. The registered provider does not monitor staff procedures and practices such as medication practices. The Registered Provider confirmed that regular supervision is being undertaken for all staff members, although written records were not requested at this visit. Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 2 17 X 18 X 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X X 2 2 2 Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 21 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 OP1 Regulation 4&5 Schedule 1 Requirement To revise both the Statement of Purpose and Service User Guide to include all of the required information detailed in the Regulations. Previous timescale 30.06.05 and 31.12.05 The Registered Provider is required to amend the Service User Contract to ensure it clearly states details of the service provided. Previous timescale 30.06.05 and 31.12.05 An application for a variation must be made for those Service Users outside the registration of the home. Previous timescale 01.11.05 The home is required to produce and implement accurate and detailed care plans with risk assessments that identify all the individual Service Users needs. Care plans and assessments must be accurately reviewed monthly or earlier if needed to ensure all changes in needs are recorded and actioned and met. Previous timescale 30.06.05 and 31.01.06 DS0000044013.V271816.R01.S.doc Timescale for action 28/02/06 2 OP2 5 28/02/06 3 OP4 12,14,18 28/02/06 4 OP7 12,13,15 28/02/06 Brenan House Version 5.0 Page 22 5 OP8 12-17 Sch 3 6 OP9 12-14 16 17 23 Sch 3 17,22, Schedule 4 7 OP16 8 OP30 12,13,18 9 OP33 10,12,15, 24 10 OP38 12,13,16, 23 All Service Users must have health assessments. To include skin integrity and nutritional assessments, these must be reviewed monthly. Previous timescale 31.12.05 All medication must be handled and administered adhering to safe procedures/practices. Previous timescale 31.12.05 The Registered Provider must record and acknowledge all concerns/complaints made including verbal complaints. Responses to complaints should be appropriate and objective. Previous timescale 31.12.05 The Registered Provider must develop and implement an induction programme for new staff that complies with TOPPS and is completed over a sufficient period of time to ensure staff have fully understood and learnt the contents of the programme. Previous timescale 30.06.05 and 31.01.06 The Registered Provider is required to develop and implement a quality assurance system and to produce a written report of the collated information gathered and any actions required. A copy must be sent to the CSCI. Previous timescale 30.06.05 and 31.01.06 Visual inspections of fire fighting equipment must be conducted at the specified time intervals. Previous timescale 31.12.05 28/02/06 19/12/05 31/12/05 31/01/06 28/02/06 31/12/05 Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 23 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 OP7 Good Practice Recommendations To review care plans/service users files to make them more user friendly Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Brenan House DS0000044013.V271816.R01.S.doc Version 5.0 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. 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