Inspection on 20/10/05 for Brendon House

This inspection was carried out on 20th October 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

Brendon House 10/02/09

Brendon House 26/08/08

Brendon House 25/10/07

Brendon House 14/11/06

Brendon House 27/02/06

Brendon House 08/02/05

Brendon House 18/10/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Brendon House Brendon Avenue Loundsley Green Chesterfield Derbyshire S40 4NJ Lead Inspector Rose Veale Unannounced Inspection 20th October 2005 10:00 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 Brendon House DS0000035785.V253296.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. Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brendon House Address Brendon Avenue Loundsley Green Chesterfield Derbyshire S40 4NJ 01629 580000 01246 347610 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) Derbyshire County Council Dawn Billyeald Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Provider evidences suitable alternative management arrangements in the event of the Registered Manager`s absence. 8th February 2005 Date of last inspection Brief Description of the Service: Brendon House is situated in the Loundsley Green area of Chesterfield, close to local shops and public transport. The home provides accommodation on two floors and personal care for up to 31 older people. There is an extensive garden, part of which has been fenced to provide a secure area for residents to use. Brendon House is owned by Derbyshire County Council and the authority has plans to provide a replacement building within the next two years. Residents and their families have been made aware of these plans. The authority has undertaken a programme of refurbishment which reflects the proposed lifetime of the building. Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over five hours on one day. There were 27 residents accommodated in the home on the day of the inspection, including 4 residents for short term care. Residents, visitors and staff were spoken with during the inspection. The care records of three residents were examined, plus other records related to the staffing and management of the home. A tour of the building was undertaken. The deputy manager was available and helpful throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: The Medication Administration Records, (MARs), were not always correctly completed, potentially affecting the safety and welfare of residents. The main entrance area and office were affected by smoke drifting through from the smoking room. Better use of extraction in the smoking room and closing the door would help to ensure a smoke-free atmosphere in the rest of the home. The kitchen for use by visitors had cracked worktops which could potentially harbour bacteria and needed replacing. There was a sliding door to the kitchen which was difficult to use and needed repairing or replacing. Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 6 Although staffing levels in the home appeared sufficient to meet the current needs of residents, there seemed to be no flexibility to allow for busier periods or the changing needs of residents. Staff records did not all contain the information required to ensure the protection of residents. 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. Brendon House DS0000035785.V253296.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 Brendon House DS0000035785.V253296.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): 2 and 5 The information provided and the opportunity to visit the home prior to admission ensured that residents could make an informed choice about living at the home. EVIDENCE: Individual terms and conditions were seen for each resident. It was a requirement at previous inspections that this must be provided and this had therefore been met. The terms and conditions contained all the required information. Prospective residents visited the home for a day so that an assessment of their needs could be made, and so that the resident could see how they liked the home. A recent assessment was seen of a resident who had visited for the day and then come into the home for short term care. Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 9 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, 9 and 10 Residents’ personal care needs appeared to be well met, with evidence of respecting dignity and privacy. Medication in the home was generally safely administered. However, there were some potentially unsafe practices to be addressed to fully ensure the safety and welfare of residents. EVIDENCE: The care records of three residents were examined, including one resident admitted for short term care. Each resident had a care plan detailing the care required to meet their assessed needs. Care plans had been developed since the last inspection and included residents’ oral care and tissue viability needs as recommended at previous inspections. Care plans were signed by the resident and had been reviewed monthly up to date. The medication system at the home was the Boots monitored dose system. All medication was stored securely. There was a separate fridge for medication with temperatures recorded daily, but not the maximum and minimum temperatures. The medication administration records, (MARs), seen were Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 10 generally correctly completed. Some MARs had no signature to show the medication had been given or a code letter to say why it had not been given. Handwritten entries on MARs did not have two signatures to show that the entry had been checked as correct. Medication received into the home was not always recorded on the MARs. Eye-drops did not have the date of opening noted. Residents spoken with said that staff were respectful in their approach, and that privacy and dignity were maintained. One resident gave the example of how staff gave assistance with bathing to ensure privacy and dignity were maintained. The preferred name of each resident was noted on their care records and residents spoken with confirmed that they were addressed in the way they preferred. The telephone for residents’ use was situated in the main office. Residents and staff spoken with felt that this was not the best location as there was little privacy. The deputy manager said the telephone had been moved from its previous location in the main entrance area as this was also felt to lack privacy. It was suggested that the views of residents and staff should be sought and the telephone placed where the majority felt privacy would be ensured. Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 11 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): 13, 14 and 15 Residents were supported to have choice and control over their lives and to maintain contact with family and friends. The meals provided in the home were of a good standard ensuring that residents were offered appealing and wholesome choices. EVIDENCE: The home had open visiting and the policy was displayed in the main entrance area. Visitors spoken with said they were always made welcome by staff and were able to see the resident in private if they wished to. Residents spoken with said they were able to follow their preferred routines, such as the time they wished to get up and go to bed. One resident said that “I can please myself”. Another resident said that staff help to “keep me independent”. One resident liked having a key to the bedroom door. The menus for the home were seen and these were varied and appeared well balanced. The cook said that the residents were consulted about the menu and different dishes were tried if asked for by the residents. The daily menu was displayed in the dining room, with details of the choices available. The dining room was bright and pleasant. One resident was helping to set the tables. At lunchtime, the vegetables and gravy were placed on the table for Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 12 residents to help themselves. There was a quiet, relaxed atmosphere at lunchtime with staff helping unobtrusively. Residents spoken with were all positive about the food, saying that meals were of a very good standard and that there was always a choice. Food preferences, likes and dislikes were noted in residents’ care records. Brendon House DS0000035785.V253296.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 Although residents said they felt able to complain if necessary, and there was evidence that complaints were properly dealt with, the complaints procedure could not be produced for inspection. EVIDENCE: The home’s complaints book was seen. It was clear form the records kept that complaints were dealt with promptly and the action taken recorded. The complaints procedure was not displayed in the home and could not be located for inspection. Residents spoken with were aware that they could complain. One resident said that complaints could be made to staff and that “things get done” if complaints are made. Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 14 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 The home provided a clean and comfortable environment for residents, despite the problems of the outdated building. However, improvements were needed to ensure a more safe and pleasant home for residents. EVIDENCE: The home was due to be replaced and was of a design which made updating to current standards difficult. As required at previous inspections, some work had been carried out to maintain and refurbish the building. The toilets on the first floor had been partly refurbished to provide improved access. New bath hoists had been provided in both bathrooms. The toilets and bathrooms remained institutional in appearance. An area of the garden had been fenced off to provide security for residents. The environmental health officer had inspected the kitchen on 5/10/05 and made one requirement that the extractor fans should be cleaned and / or repaired – this was being organised on the day of this inspection. There was a smoking lounge just off the main entrance area. As the door to this lounge was open and the extractor fan was turned off, the smoke drifted Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 15 into the main entrance area and the main office. The deputy manager took action on the day of the inspection to ensure the extraction fan was turned on and the door closed. There was a small lounge for use by visitors with a kitchen attached. The worktops in this kitchen were cracked and in need of repair or replacement. The sliding door to this kitchen was difficult to operate and needed repair or replacing. The carpets in the large lounge and dining area were very stained and needed replacing. The bedrooms seen were well decorated, bright, comfortable and well personalised with residents own possessions. Residents spoken with were pleased with their rooms. One resident said it was “home from home” because of having personal items in the room. All areas of the home were clean. Residents and visitors spoken with said the home was always clean. Brendon House DS0000035785.V253296.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 and 29 There were sufficient staff on duty to meet the needs of the current residents. However, there appeared to be little flexibility to allow for extra provision at busy times or to meet the changing needs of residents. Staff records did not contain all the required information to ensure the protection of residents. EVIDENCE: The staff rota for the home was seen and there appeared to be sufficient staff to meet the needs of residents. Residents spoken with said that staff were usually available when needed. Staff spoken with felt that staffing levels were adequate at present as there were some residents in hospital, but when the home was full and depending on the needs of residents, their workload could be very busy. There did not appear to be flexibility around providing additional staff at busy times. Staff records were examined. Of the four records seen, only one had all the required information, including a copy of the Criminal Records Bureau, (CRB), disclosure, application form, two written references, and recent identification including a photograph. Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 17 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 and 37 The home appeared generally well managed, providing a relaxed atmosphere for residents. EVIDENCE: At the time of this inspection, the registered manager for the home had been on long term sick leave for about a year. An acting manager had been appointed and had been given additional hours. The acting manager and other senior staff were supported by a service manager. Staff spoken with said the acting manager was “doing a good job” and there was evidence that action had been taken by the acting manager to meet requirements made at the last inspection. Although Standard 33 was not assessed at this inspection, a requirement made regarding this standard at the last inspection was followed up. The requirement was that there should be monthly unannounced visits to the home Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 18 by a representative of the providers. Records of these visits were seen and the requirement had therefore been met. Records kept in the home were securely stored. In one care file seen, the front sheet was missing. The daily logs seen did not include the time of writing and there were blank spaces left after entries made. Current good practice is to note the time of entries made and to put a line through any blank spaces to guard against fraud. It was a requirement at the last inspection that a list of residents possessions must be kept in their care records. This was seen on the records of long term residents and the requirement had therefore been met. Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 19 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 3 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X 2 X Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(3) Requirement The Medication Administration Records, (MARs), must be correctly completed with the initials of the person giving the medication, or a code letter to indicate why medication was not given. All medication received into and leaving the home must be recorded The maximum and minimum temperatures of the medication fridge must be recorded daily The complaints procedure must be available for residents and their representatives, and for inspection Action must be taken regarding the use of the smoking room to ensure a smoke-free environment in the rest of the home The worktop in the kitchen for the use of visitors must be replaced The sliding door to the kitchen for the use of visitors must be repaired or replaced The manager must ensure that DS0000035785.V253296.R01.S.doc Timescale for action 30/11/05 2 3 4 OP9 OP9 OP16 13(3) 13(3) 22 30/11/05 30/11/05 30/11/05 5 OP19 23(2) 30/11/05 6 7 8 OP19 OP19 OP27 23(2) 23(2) 18(1)(a) 31/03/06 31/03/06 31/12/05 Page 21 Brendon House Version 5.0 9 OP29 19(1)(b) staffing levels meet required standards and are responsive to the changing needs of residents Original timescale 31/01/05 Staff records must contain all the 31/01/06 information required in Schedule 2 (Care Homes Regulations 2001) 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 2 3 4 Refer to Standard OP9 OP9 OP10 OP37 Good Practice Recommendations Handwritten entries on MARs should be signed by the person making the entry and also by the person checking that the entry is correct The date of opening eyedrops should be noted so that the eyedrops are disposed of after the specified time Consultation should take place with residents and staff determine the best position for the telephone to ensure privacy when making calls Entries in the daily logs should include the time the entry was made and any blank spaces should have a line through to guard against fraud. Brendon House DS0000035785.V253296.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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