Inspection on 15/11/05 for Briar Close House Care Home

This inspection was carried out on 15th November 2005.

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

Briar Close House Care Home 06/02/07

Briar Close House Care Home 11/05/05

Briar Close House Care Home 03/11/04

Briar Close House Care Home 11/05/04

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 Briar Close House Care Home Briar Close Borrowash Derby DE72 3GB Lead Inspector Janet Morrow Unannounced Inspection 15th November 2005 10:25 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 Briar Close House Care Home DS0000035731.V266673.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. Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Briar Close House Care Home Address Briar Close Borrowash Derby DE72 3GB 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) 01332 718310 01332 718311 linda.trigg@derbyshire.gov.uk Derbyshire County Council Linda Joy Trigg Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2005 Brief Description of the Service: Briar Close is a 40 bedded home for older people situated in the village of Borrowash, near the city of Derby. Three places are available for respite care and three places for day care each day. The property was purpose built and is owned by the local authority, Derbyshire County Council. Service users bedrooms are situated on the ground floor. The first floor is used for staff facilities only and is accessed by stairs. There are no en-suite facilities. All bedrooms are attractively decorated and personalised. Communal areas are bright and décor is of a good standard. The home is divided into four units for ten people, each having its own kitchenette, and dining and lounge area. In addition, there is a large lounge at the entrance to the building. There is a garden area with outdoor seating. Support services are in place with a choice of General practitioners, and visiting district nurses, chiropodist, dentist and optician. Community psychiatric nurse, occupational therapist, physiotherapist and dietician are accessed as required. Staff training takes place to inform and enable staff to care for service users appropriately. Transport is arranged for those service users wishing to go out and in-house entertainment is arranged. Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over 5.5 hours. Care records were examined. A partial tour of the premises took place. Twelve of forty service users, two relatives and two visiting professionals were spoken with. A lunch time meal was sampled. Written information was provided by the home for the inspection process. What the service does well: What has improved since the last inspection? Information on care plans was more specific to individual needs and information about risks to residents were updated regularly. Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 Page 6 The information kept on residents’ files had improved and ensured that the home met its obligations under the Care Homes Regulations 2001. An enhanced security system had been installed which made residents’ safer. Financial information about the home’s budgets was available. The complaints procedure on display had been updated to include the correct details of the Commission for Social Care Inspection. New curtains had been purchased for the corridors. 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. Briar Close House Care Home DS0000035731.V266673.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 Briar Close House Care Home DS0000035731.V266673.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): 3, 4 and 5 The home was able to provide relevant care and meet residents’ needs based on the assessment information provided on admission and offered residents and their relatives the opportunity to assess the suitability of the home. EVIDENCE: Three residents’ files were examined and there was assessment documentation in place in each that provided sufficient information over a range of needs for staff to provide care following admission. Those residents and their relatives spoken with stated that their care needs were met and visiting professionals interviewed during the inspection visit also confirmed that needs were met. One resident commented that they ‘couldn’t find anything wrong’. A review of care organised by a visiting professional was observed and this showed that needs were met and that both resident and relative were pleased with the care provided. The feedback was very positive with comments such as the staff ‘go out of their way to help’ being made. Due to the positive comments received, the home is commended for the efforts it makes in meeting individual needs. Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 Page 9 One relative interviewed confirmed that they had visited the home prior to admission and a visiting professional also confirmed that introductory visits to assess the suitability of the home were available. Briar Close House Care Home DS0000035731.V266673.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): Health care needs were met but additional checks on medication administration procedures would minimise risk of errors. EVIDENCE: Care planning and assessment information was available on three care files examined. This showed that plans were personalised and provided sufficient detail for staff to ensure health and personal care needs were met. Plans were reviewed monthly and identified risks had appropriate actions detailed. For example, where a nutritional assessment had identified a risk, there was monitoring of weight and regular re-assessments. Falls risk assessments were also available on all three files examined and where a risk was identified, appropriate actions, such as encouraging chairbased exercises, were recorded. Signatures were available on those care plans seen, indicating that consultation about care took place. Residents interviewed confirmed that they had access to dentists, opticians and chiropodists and this was verified on the written records seen. The medication administration record (MAR) charts for three residents’ were examined. These were found to be in order and corresponded accurately with the dosage system. However, handwritten medication administration record Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 Page 11 (MAR) charts were not signed and dated by two people. This had the potential for errors to occur. The medication refrigerator temperatures were recorded daily. The manager stated that there were no controlled drugs on the premises. Those residents who were self medicating had been assessed to check that it was safe to do so. A copy of the Royal Pharmaceutical Society Guidelines was available. A recent medication error was discussed. This had occurred as two people were involved in the administration of medicines and the responsible member of staff had not been able to observe the other staff member. This method of medication administration should be reviewed to ensure that any potential risk of error is minimised. The home had a short policy on death and dying and the manager was able to demonstrate in discussion that she was aware of the needs of the dying and how to access specialist help when required. A more comprehensive policy would be beneficial to staff and ensure that palliative care needs were fully understood. Briar Close House Care Home DS0000035731.V266673.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 and 15 Social activities and meals were both well managed, which enhanced residents’ daily lives. Residents were enabled to have choice and control over their lives. EVIDENCE: A range of activities was on offer including plant growing, chair exercises, cooking and painting. Meals out and visits to places of interest also occurred. Some residents visited local facilities such as the pub. One resident spoken with had particularly enjoyed the trips out which included a boat trip and an outing to the coast. Musical entertainment took place during the inspection. The serving of the lunchtime meal was observed and a meal sampled. This showed that individual preferences were taken into account and that the food was well cooked, wholesome and nutritious. Residents spoken with during the lunchtime meal enjoyed the food. Home baking of cakes took place for special occasions such as birthdays. Those visitors spoken with confirmed that they were able to visit when they liked and were made to feel welcome at the home. Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 Page 13 Individual choice was facilitated as far as possible. Residents were able to bring personal possessions into their bedrooms and some managed their own finances. The manager was aware of how to access advocacy services when necessary but stated that no residents currently had an advocate. Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 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): 17 and 18 Legal rights were upheld and policies and procedures ensured that residents were protected from abuse. EVIDENCE: The manager stated that residents were all registered for a postal vote and that those who wished to had taken part in the general election. A detailed policy and procedure on adult protection was in place, including the Derby and Derbyshire Local Authority Social Services procedures, and records showed that staff training had taken place in house and had been followed up through the supervision process. The written information supplied by the home stated that there had been no incidents requiring investigation during the last twelve months. Briar Close House Care Home DS0000035731.V266673.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, 25 and 26 The home was well maintained and provided safe, comfortable and homely accommodation for residents. However, further improvements, particularly in relation to one outstanding matter, were required which would enhance the environment. EVIDENCE: A tour of the building showed that the home was bright and cheerful with good quality furnishings and fittings. New curtains had been purchased for the corridors. However, remedial work to flaking paint on the exterior had not been undertaken and made the exterior look shabby. This was raised as an issue at the previous inspections in November 2004 and May 2005. The manager had correspondence that showed she had chased this up with the Local Authority and was hopeful that it would be rectified in the near future. There was also some damaged paintwork and wallpaper in one lounge area. Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 Page 16 Rooms were centrally heated and naturally ventilated. Pipework and radiators were guarded. The home was clean, tidy and free from offensive odours. Laundry facilities were sited separately and policies and procedures were available for the control of infection. The washing machines had a sluicing facility. One relative interviewed stated that they had been impressed with the general cleanliness of the home and described it as ‘very clean’. Security locks had been placed on the office, sluices and the medical room and a new security system to alert staff to the opening of fire doors had been fitted. Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 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): 28 Staff had good access to qualification courses, which ensured that they were competent at their jobs. EVIDENCE: The written information provided by the home showed that sixteen of eighteen care staff (88 ) had achieved a National Vocational Qualification (NVQ) at level 2. This therefore exceeded the target of 50 of staff achieving this by 2005. Two newer staff were also due to start the training in the near future. The Local Authority had placed emphasis on this qualification by making it mandatory for all care staff. The home and the Local Authority are therefore commended for their efforts in achieving this level of qualifications. Briar Close House Care Home DS0000035731.V266673.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, 34, 35, 37 and 38 The home was well managed and run in residents’ best interests. EVIDENCE: The manager had achieved the Registered Manager’s award and had many years experience in managing the home. In discussion, she demonstrated that she was familiar with the conditions associated with old age. She was committed to providing a good service and keen to ensure that standards continued to be achieved. Residents and relatives spoken with were clear who was in charge and were confident of a courteous response to any concerns. The Local Authority had a quality assurance process external to the home. Age Concern had undertaken a survey on behalf of the Authority and the summary of their findings was on display. This showed that the care service provided was good. The home also did its own quality assurance questionnaire for residents on an annual basis. Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 Page 19 The financial records for three residents were examined. This showed that proper accounting procedures were in place and receipts for purchases were available. All three records examined corresponded with the cash held. The annual budget for the home was also seen and this showed that the home was able to operate within its budget. Although there was no formal written financial plan available, the manager was clear about what the spending priorities were for each year within the allocated budget. A valid insurance certificate was on display. The care records examined showed that these were clear and legible and contained all the information required by Schedule 3 of the Care Homes Regulations 2001. The written information supplied by the home showed that the maintenance of equipment, such as fire equipment, electrical wiring and emergency call system was up to date. Staff training was also recorded on the information provided by the home and showed that health and safety was addressed by the provision of courses on moving and handling, first aid and fire safety. Briar Close House Care Home DS0000035731.V266673.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 X X 3 4 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 2 X X X X X 3 3 STAFFING Standard No Score 27 X 28 4 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 3 3 X 3 3 Briar Close House Care Home DS0000035731.V266673.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 op19 Regulation 23(2)(b) Timescale for action Identified external areas must be 01/01/06 repainted. Previous timescales of 1/5/05 and 1/8/05 not met. There must be arrangements for 01/01/06 the safekeeping, handling, safe administration, recording and disposal of medicines received into the home. All parts pf the home must be 01/05/06 reasonably decorated. Requirement 2 OP9 13 (2) 3 OP19 23 (2) (d) 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 Refer to Standard OP9 OP9 Good Practice Recommendations Handwritten medication administration record (MAR) charts should be signed and dated by two people. The current system of administering medication should be reviewed to ensure that the person signing the medication administration record (MAR) chart is fully aware that the medicine has been administered correctly. DS0000035731.V266673.R01.S.doc Version 5.0 Page 22 Briar Close House Care Home 3 4 5 OP11 OP19 OP34 A more comprehensive policy on care of the dying should be available. The damage to paintwork in the identified lounge should be rectified. A written financial and business plan that identifies spending priorities for the home should be available. Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 Page 23 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 Briar Close House Care Home DS0000035731.V266673.R01.S.doc Version 5.0 Page 24 - 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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