Inspection on 27/02/06 for Brendon House

This inspection was carried out on 27th February 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

Brendon House 10/02/09

Brendon House 26/08/08

Brendon House 25/10/07

Brendon House 14/11/06

Brendon House 20/10/05

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 27th February 2006 10:30 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 Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 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.V282621.R01.S.doc Version 5.1 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.V282621.R01.S.doc Version 5.1 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. 20th October 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 that reflects the proposed lifetime of the building. Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 5 hours. There were 29 residents accommodated in the home on the day of the inspection, including 5 residents receiving short-term care. Residents, visitors and staff were spoken with during the inspection. The care records of 4 residents were examined, plus other records relating to the staffing and management of the home. A full tour of the building was not undertaken, although some bedrooms, communal areas, bathrooms, toilets and the laundry were seen. The temporary deputy unit manager was available and very helpful throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: The medication for short-term care residents was not routinely recorded when received and disposed of. This must be addressed to ensure the safety of residents. Further recruitment was needed to ensure staffing levels were always able to meet the changing needs of residents. Staff records did not all contain the required information to ensure the protection of residents. Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 Page 6 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.V282621.R01.S.doc Version 5.1 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.V282621.R01.S.doc Version 5.1 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): 3 The assessment information was satisfactory to ensure that residents’ needs could be met by the home. EVIDENCE: The care records of 4 residents were examined, including an emergency admission and a resident admitted for short-term care. All the records had assessment information including the Community Care Assessment. Residents admitted for permanent care had spent a day in the home prior to admission for assessment. Some permanent residents had previously stayed in the home for short-term care. Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 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 and 8 The personal care needs of residents appeared to be well met with good liaison with other health care professionals. EVIDENCE: Of the four care records examined three had care plans in place. The one without a care plan was the person recently admitted in an emergency. The care plans seen were detailed and included all the assessed needs of residents. The care plans had been reviewed monthly up to date. Records were seen of the visits / input of other health care professionals – GPs, District Nurses, chiropodist, optician, dentist, and so on. There was evidence of prompt referral to other services as required. For example, one resident had been referred to the GP with a painful knee, another resident had been referred to the GP and District Nurse for treatment of a skin condition. One resident spoken with had been seen by the hospital dietician and another resident had attended the audiology department. Residents and visitors spoken with said that the GPs were contacted without delay when needed. Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 Page 10 Staff spoken with were knowledgeable about the care needs of residents and were clearly familiar with residents preferences regarding how their care should be carried out. Requirements made at the last inspection regarding the safe handling of medication were followed up. Two requirements had been met. One requirement to record all medication received into and leaving the home had not been met as the medication for short-term care residents had not been recorded. Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 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): 12 There was a good programme of activities offered to residents to meet their social and recreational needs. EVIDENCE: The home employed two activities coordinators who between them worked 35 hours per week. There was a good programme of activities offered to residents, including trips out, visits to the theatre, meals out, bingo, coffee mornings, singalongs, and visiting entertainers. There were also one-to-one activities such as manicures and hand massages. A visit by local primary school children was planned. Records were kept of the activities. Residents meetings were held approximately monthly. A newsletter was produced every month which included information for residents on staff news, new residents, deaths, new furnishings, and other events in the home. Residents spoken with were pleased with the activities offered and enjoyed the newsletter. The weekly coffee morning was a clear favourite and was usually well attended. The activities coordinator spoken with was enthusiastic about her role and had plans for future activities, including a regular church service and an Easter bonnet competition. The care records seen included information about the preferences of residents regarding their daily routines. Residents spoken with said that routines were Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 Page 12 generally flexible. Staff spoken with were aware of the individual preferences of residents and of the importance of maintaining independence. Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 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): 18 Residents were protected by the systems in place in the home and by staff awareness and attitudes. EVIDENCE: The home had policies and procedures for protecting residents from abuse, including the Derbyshire County Council multi-agency guidelines and a whistle blowing policy. Most of the staff had received training in safeguarding vulnerable adults. Staff spoken with were aware of the procedures to follow in the event of suspected abuse. Residents and visitors spoken with said they would be able to raise any concerns with the staff. At the last inspection the complaints procedure was not available in the home and a requirement was made to address this. At this inspection the complaints procedure was displayed on the notice board in the main entrance area. Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 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 and 26 No progress had been made on providing a new home to replace the outdated building. Despite the problems, the home provided a generally pleasant and clean environment for residents. EVIDENCE: There were plans to replace the home as the building was outdated and of a design which made updating to current standards difficult. Although the plans for a new home had been known about for some time, the staff were unaware of any definite timescale. Some work had been carried out to maintain and refurbish areas of the building, such as the ground floor toilets. New carpets had been ordered for the lounge and dining area. Residents spoken with confirmed that they had been involved in the choice of colour of the carpet. The toilets were institutional in appearance and the bathrooms were unwelcoming. At the last inspection, a requirement was made regarding the smoking lounge as smoke was drifting into other areas of the home. Staff said that the extraction fan was used as much as possible, although residents often turned it Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 Page 15 off. It was noted that the smell of smoke was not so obvious as it was on the previous inspection. Requirements were made at the last inspection for the worktop and sliding door in the small kitchen for use by residents / relatives to be repaired or replaced. The senior staff spoken with said that this work had been reported and was ‘in hand’, though no definite date for the work was known. It was noted that the splashback to the worktop was coming away from the wall. The laundry was seen and, like other areas of the building, was in need of general refurbishment. The laundry was well equipped, clean and tidy. Staff spoken with were aware of infection control measures, such as effective hand washing, wearing disposable gloves and aprons when helping with personal care, and disposing correctly of clinical waste. Staff were observed wearing tabards when assisting with meals. Staff training in infection control had been arranged. The home was clean and free from offensive odours on the day of inspection. Residents and visitors spoken with were satisfied with the cleanliness of the home. Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 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): 28, 29 and 30 Residents were supported by a well trained and competent staff team. Some progress had been made in providing extra staff, however, further recruitment was necessary to ensure the changing needs of residents could always be well met. EVIDENCE: The staff training records were seen and training was discussed with staff. Most of the care staff had achieved NVQ Level 2 in care. Staff had received training in fire safety, adult protection, first aid, and moving and handling. Staff had also received training relevant to their work, such as dementia awareness and coping with challenging behaviour. At the last inspection it was found that although there appeared to be sufficient staff on duty, the staffing levels were not always flexible to allow for extra provision at busy times or to meet the changing needs of residents. Since the last inspection, new staff had been employed at the home and this had helped with maintaining staffing levels. Staff spoken with said some staff were regularly working extra hours to provide the cover needed. There was a parttime vacancy for afternoon kitchen staff. The care staff spoken with said this created problems when there was no kitchen assistant working in the afternoon as the care staff were then responsible for preparing the tea, taking one carer away from caring for residents. The staff rota was seen and showed that the agreed staffing levels were generally being maintained, albeit through staff working extra hours. Residents spoken with said the staff were Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 Page 17 ‘wonderful’ and ‘did their best’ but were ‘overworked’. One resident commented that residents in the home had become more dependent over the last few years and that staffing levels did not appear to have changed to allow for this. A requirement was made at the last inspection that staff files must include all the required information. Staff files checked at this inspection did not include all the required information and this requirement has been carried forward in this report. Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 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): 33, 35 and 38 The health, safety and welfare of residents were protected by the systems in place in the home. EVIDENCE: The owners of the home, Derbyshire County Council, had carried out a quality assurance survey in 2005. The analysis and results of this survey were available in the main entrance area. The report included action to be taken to improve the service based on the comments received. Quality assurance at the home was also monitored through the residents meetings, the weekly coffee mornings, monthly visits by a senior manager, and care reviews. The records were seen for residents’ personal money held at the home. The records were well kept and up to date. Transactions were signed by two members of staff and receipts were kept. Money was stored securely. Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 Page 19 The home had a health and safety policy. Risk assessments of the environment had been carried out and regularly reviewed. Records relating to health and safety were examined, including the fire log book, accident book, and maintenance and servicing records. The records seen were up to date. Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 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 OP9 Regulation 13(3) Requirement All medication received into and leaving the home must be recorded. Original timescale 30/11/05 Timescale for action 30/04/06 2. 3. OP19 OP29 23(2) 19(1)(b) The splashback in the kitchen for 31/05/06 the use of visitors must be repaired or replaced. Staff records must contain all the 30/04/06 information required in Schedule 2 (Care Homes Regulations 2001) Original timescale 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 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. Extracts may not be used or reproduced without the express permission of CSCI Brendon House DS0000035785.V282621.R01.S.doc Version 5.1 Page 23 - 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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