Inspection on 20/12/05 for Briar Dene

This inspection was carried out on 20th December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Briar Dene 19/02/09

Briar Dene 09/10/08

Briar Dene 25/10/06

Briar Dene 07/02/06

Briar Dene 02/03/05

Briar Dene 09/09/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Briar Dene 71-73 Burniston Road Scarborough North Yorkshire YO12 6PH Lead Inspector Gill Sample Unannounced Inspection 20th December 2005 11:15 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 Dene DS0000007634.V271413.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 Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Briar Dene Address 71-73 Burniston Road Scarborough North Yorkshire YO12 6PH 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) 01723 361157 01723 361157 Mr John Kelly Mr John Kelly Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2005 Brief Description of the Service: Briar Dene is a large, detached property standing in its own well-maintained grounds on the north side of the town. The care home is located reasonably close to all main community facilities including the public transport network. There are parking spaces available for several vehicles. The building, a former hotel, has been adapted to provide personal care for a maximum of 27 service users who are accommodated by virtue of age or infirmity. The home provides 25 single and one shared bedroom, all with ensuite facilities, on two floors. There is a passenger lift serving the two floors. The registered provider and his staff give personal care including support with personal hygiene where necessary. Nursing care is not provided at the home. Should such care be required on a short-term basis then it will be provided by the community health care services. There is an in-house catering service, laundry facilities and a cleaning and domestic service. Staffing cover for the home is maintained over a 24hour period on each day. Leisure and recreational activities are offered in the home and at various locations outside. Many service users are able to go out either unaided or with the assistance of visitors or staff. Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report gives the findings of an unannounced inspection which was made on 20th December 2005. The inspection focussed on a number key standards and those requirements and recommendations made at the last inspection. Some of the premises were inspected including a number of bedrooms, bathrooms and living areas. A range of written records were also examined. Residents were spoken with both individually and in small groups and three of these service users’ records were examined. Discussions were held with the deputy manager and staff at the home and with Mr. Mark Kelly, son of the registered manager, who was working at the home. A discussion with two visitors to the home formed part of the inspection. What the service does well: What has improved since the last inspection? What they could do better: There were no requirements made as a result of the inspection. Recommendations have been made about replacing the call bell system as calls made by service users in their rooms can be cancelled centrally. Because care was being provided to service users in their final illness, this will assist care staff to support service users with increasing need. Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 6 Staff employed are not issued with a contract of employment and a recommendation has been made to do so. The record of assessment of fire risk could be recorded in one document which will ensure that all areas of risk are being addressed and may make the assessment easier to complete and update. 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 Dene DS0000007634.V271413.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 Dene DS0000007634.V271413.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. Standard 6 does not apply. Prospective residents are provided with information about the home which includes the services and facilities offered by the home and how their needs would be met. Details of needs are gathered and recorded prior to any person being admitted to the home so that they can be assured these can be met. EVIDENCE: Three service users’ records were examined, one of which was for a resident who had been very recently admitted to the home. These showed that comprehensive personal information had been gathered and recorded along with the particular needs of the individual. The risks associated with providing care or with the environment in relation to the resident were also recorded. Service users said that they had chosen some aspects of their care, for instance, about when and how many baths they took each week. Briar Dene DS0000007634.V271413.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, 8, 9 and 10 The health and personal care needs of service users are recognised and recorded so that service users can be sure that they are being looked after. EVIDENCE: Records of care given showed details of the physical care to be provided to individual service users. Two service users had a terminal illness and the deputy manager on duty said that the intention was to care for these people within the home with the assistance of community nursing staff rather than them needing to be admitted to hospital. The case record of one of these two residents were examined which confirmed that the changing health care needs were being recognised and addressed. Staff were observed helping service users in a kind and respectful way. Some service users need less help with day to day life but one said “the service is there if I need it” and another “the girls are very nice, nothing is too much trouble”. The medication system and recording were seen. Administration of medication is done using a monitored dosage system provided by a qualified pharmacist. The procedures for the receipt, recording, storage, handling and disposal of medicines was seen and discussed with the deputy manager. Care records recorded where service users had chosen to deal with their own medication. One service user was accompanied by a member of staff to an outpatient appointment at hospital during the inspection. Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 10 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 Daily life and social activities offer service users opportunities to live their preferred lifestyle and retain relationships in the wider community. EVIDENCE: Service users spoken with individually and in groups said that they were very happy with their lifestyle at the home. One service user who had been recently admitted said that she had felt supported by other residents to get her bearings in the new surroundings of the home. Two visitors to the home were spoken with. They said that the atmosphere of the home was welcoming that staff are always friendly and that they were able to visit whenever they wished. One commented that she continues to visit and had been involved in preparations for Christmas. Service users were seen receiving visitors or going out with relatives throughout the inspection. A concert was being held in the afternoon given by a singer and piano accompanist. Notices were posted about activities offered at the home and service users said that there was an organiser employed who provided a variety of activities. Service users described the Christmas celebrations over the festive period and the home had been decorated for Christmas which service users clearly enjoyed. Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 11 Service users said that they enjoyed the meals served at the home and were offered a choice. One service user showed the dining room which was well decorated and enabled service users to eat alone or with others as they wished. Lunch served looked appetising and nicely presented and staff were attentive to service users’ needs when serving the meal. Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Service users are able to make a complaint using information provided by the home. Service users are protected by the awareness of staff of potential abuse. EVIDENCE: A complaints policy and procedure are in place. People resident at the home are given information on how to complain by means of a notice in each room. The procedure includes timescales for investigation and response to any complaint made. Service users spoken with said they had had no occasion to make a complaint, but would speak initially to the registered manager if they needed to. The registered manager has access to the local authority’s protocol on the protection of vulnerable adults. The Deputy Manager showed awareness of the need to ensure that service users are kept safe and that any potential abuse is recognised and addressed in the proper way. Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 13 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 People living at the home live in a clean and well maintained environment though their needs will be better met by the provision of suitable equipment. EVIDENCE: A number of bedrooms, bathrooms and communal areas of the home were seen. All areas were well decorated and furnished in keeping with the overall style of the building and it’s layout enables service users choose to have company or not. Those parts of the home seen were uniformly warm and free from unpleasant odours. Hoisting equipment is available to assist staff when moving and handling residents with these needs on the first floor. The examination of care records and discussion with the deputy manager showed that no hoist is available on the ground floor where a resident who needs assistance to move and walk lives. Following discussion with the deputy manager, advice was given to review and record the manual handling risks to the service user and any assisting staff. If this assessment shows a need for lifting equipment advice Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 14 should be sought from an occupational therapist so that appropriate lifting equipment can be sourced and provided. The call bell system was tested and staff responded promptly. The call bell system in place can be cancelled away from the point of call and was discussed with Mr. Mark Kelly who said that he had begun research to source a new system with a view to its replacement. Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Staffing levels are at a sufficient level to ensure the needs of service users are met. EVIDENCE: Staffing arrangements are such that staff are available to provide care to service users at times of increased demand and in sufficient numbers to address service users’ assessed needs. Service users said that staff have the time to spend with them and this was observed throughout the inspection, with staff able to accompany a service user to a hospital appointment. Staff are employed to provide the care tasks required by service users, and in addition cooking/kitchen staff, domestic assistants and staff to serve meals are employed. Two deputy managers are employed who provide cover seven days per week. Staff training records are maintained on individuals’ files. The deputy manager in charge was advised to maintain records of staff training achieved and required in a way which will give an overall view which may easily identify outstanding need and inform budgetary planning. Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 16 The process of recruitment and selection of staff was examined by examination of staff records. These showed that the system is designed to prevent a person who is unsuitable to work with vulnerable adults being employed. Staff records were in need of reorganisation to enable information to be retrieved easily. The criminal records disclosures made on staff employed at the home were being held as original documents, and some were for staff who had left their employment at the home. Discussion with staff and the deputy manager revealed that staff have not been issued with a contract of employment or terms and conditions relating to their employment. Briar Dene DS0000007634.V271413.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, 33, 35 and 38 The health, safety and welfare of service users is addressed by the arrangements to ensure the building and its systems are maintained in a safe manner though the recording of the fire risk assessment could be improved. EVIDENCE: Mr. John Kelly owns and operates the home and is also registered as manager. The registered provider has yet to achieve a National Vocational Qualification at level 4 in both management and care. The registered provider has a considerable number of years experience in managing the care home and demonstrated a good understanding of the needs of older people. There were clear lines of accountability within the home. Two managers are employed who take responsibility for the operation of the home while on duty, and the son of the registered provider, Mr. Mark Kelly was working at the home. Service users said they had no complaints about the service but were able to identify how they would deal with any dissatisfaction or complaint and had Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 18 written information to assist them to do so if they wished. A suggestion and/or complaints book was available in the main hallway of the home containing some suggestions which had been addressed and recorded. A number of documents were seen relating to the arrangements at the home to ensure that the building and systems in place comply with health and safety legislation. These were:• • • Fire training records Fire equipment servicing and records of testing Environmental Health Department visits dated October 2004 Speaking with Mr. Mark Kelly about the fire risk assessment of the building, its occupants and activities, a document was supplied to Mr. Kelly to ensure that the assessment made is thorough and recorded on a regular basis. A risk assessment was seen about hot surface temperatures of radiators at the home. This was required as a result of the last inspection made in March 2005. Briar Dene DS0000007634.V271413.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 2 Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 22 Good Practice Recommendations Suitable lifting equipment should be available to assist with the assessed manual handling needs of service users. The call bell system should be suitable for the assessed needs of service users and not be capable of a call being cancelled without staff responding at the point of call. Criminal records disclosures obtained in respect of staff should be maintained for six months as an original document and after this time can be kept as a list detailing the name, date and disclosure number. Staff records should be maintained so that information is maintained in an organised way. Staff should be issued with a contract of employment or statement of terms and conditions in relation to their work at the home. Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 21 2 29 3 4 5 30 31 38 An overall record of staff training achieved and required should be maintained. The registered provider should obtain a National Vocational Qualification at level 4 in both management and care. The registered manager should consider recording the fire risk assessment for the home in one document an example of which was supplied. Briar Dene DS0000007634.V271413.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Dene DS0000007634.V271413.R01.S.doc Version 5.0 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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