Inspection on 25/10/06 for Briar Dene

This inspection was carried out on 25th October 2006.

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 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 07/02/06

Briar Dene 20/12/05

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 Key Unannounced Inspection 25th October 2006 10:15 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.V317560.R01.S.doc Version 5.2 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.V317560.R01.S.doc Version 5.2 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 F/P01723 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.V317560.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th February 2006 Brief Description of the Service: Briar Dene is a large, detached property standing in its own 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 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 en-suite facilities, on two floors and there is a passenger lift. Mr. John Kelly is the registered provider/manager and Mr. Mark Kelly helps in management of the service. Mr. Kelly together with a staff team made up of care staff, kitchen, dining room and domestic staff, provide accommodation, personal care, meals, laundry and domestic services. An activities organiser provides leisure and recreational activities for service users on a weekly basis, and many service users are able to go out unaided or with the assistance of visitors or staff. Information, including Commission for Social Care Inspection reports, is given to new and existing service users to the home detailing the accommodation, facilities and services provided. The weekly fee is quoted by the provider as being £350.00 to £375.00 per week in September 2006. Service users pay separately for hairdressing, private chiropody, toiletries, magazines, papers and transport. Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report gives the findings of a key inspection of the service including a site visit which was made on 25th October 2006. The inspection focussed on certain key standards and those recommendations made at the last inspection. A total of six hours and fifteen minutes was spent at the home. There were twenty-six residents living at the home. Prior to the visit, the registered providers had provided written information about the service to the Commission and the background history of the home was analysed using records held at the Commissions York office. At the visit, general areas of the premises were seen and a number of bedrooms, bathrooms and living areas. Some written records were also examined and practice was observed during the visit. Individual discussions were held with residents, with Mr. John Kelly the registered manager, Mr. Mark Kelly and staff on duty at the time. Written comment cards were distributed to service users at the visit to the service and discussions with visitors to the home formed part of the site visit. What the service does well: What has improved since the last inspection? There were no requirements made at the last inspection. Recommendations were made about replacing the system for service users to summon help from staff, about keeping personal information about criminal records disclosures in a different way to protect personal information and to issues contracts of employment for staff. These recommendations have been repeated because these have still to be achieved. Other recommendations made about the organisation of staff records, obtaining suitable hoisting equipment, keeping an overall record of staff training achieved and required and making a fire risk assessment of the building have been achieved. Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 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.V317560.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply. Quality in this outcome area is good. Service users can be assured that their needs will be properly assessed and recorded before entering the home so that their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five case records were examined, one of which was of a service user who had been recently admitted to the home and one of a service user whose stay at the home was to recuperate from surgery. These showed that prior to admission, comprehensive information had been obtained about the person, their circumstances and background, and any needs which were to be met. Less information had been gathered about the service user whose stay was temporary, but discussion with senior care staff confirmed that staff were aware of the individual needs of this service user. Discussion with a service user and their family confirmed that they had had chance to visit the home prior to admission. Information provided by purchasing authority is used as a basis for the service’s assessment of need and development of care plans, if this is available. Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. Service users can be assured that their health care will be properly monitored and dealt with and that their physical, social and emotional needs will be recognised and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The medication system in place was seen. The service uses a monitored dosage system supplied by a pharmacist on a twenty eight day cycle. Records were up to date and initialled by care staff to record when medication had been given and had been noted when refused. Secure storage of medication and controlled drugs was seen. There were several service users who self medicate but have their medication supplies organised through the home, and records were seen so that staff at the home have details of the medication of these service users. Care records seen showed that individual needs had been identified and detailed how these would be met. Records showed how health care needs had been recognised and monitored and where these had been referred for advice or attention from medical professionals. At the visit to the service a service Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 Page 10 user was taken ill. This was immediately recognised and responded to by care staff in a sensitive and caring way. Care planning reflected changes in physical weight and detailed all areas of service users’ care, such as sleeping patterns. Care needs had been reviewed and recorded on care planning documentation where needs had changed. Service users said that staff are sensitive to their privacy and dignity when providing personal care. Care records noted how service users wish to be addressed. Pre inspection information showed that service users are registered with their own medical practitioner, and the service relates to seven surgeries in Scarborough and the surrounding area. One service user confirmed that she was registered temporarily with a local surgery and had received visits from community nursing staff based there. The call bell system in place at the home can be cancelled away from the point of call. Because several service users are increasingly ill and frail and are consequently more dependent on staff, the system is in need of replacement so that service users can be guaranteed that they can summon help when they need it. The registered provider has made enquiries about installing a new system more suitable for the assessed needs of service users, but the old system has yet to be replaced. Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Daily life and social activities offer service users opportunities to live their preferred lifestyle and retain relationships in the wider community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Organised activities were seen at the visit to the service in the form of an informal quiz about everyday activities. Activities at the home are offered three times per week in specific sessions provided by an activities organiser. Visitors were seen throughout the day, some to spend time with their relative at the home and others on outings outside the home. Visitors spoken with said that they were always made welcome at the home “I’m always made welcome, like one of the gang” “you just have to ask for a cup of tea and its done”. Service users had formed friendships between themselves and said they were able to do as they wished “you can just get on with it”. Lunch was seen being prepared and served. This meal looked and smelt appetising and was seen being liquidised for those unable to swallow and set onto trays for service users taking meals in their own rooms. There are dining room staff who serve residents and clear tables. The dining room is set so that service users sit on their own table unless they wish to sit with others and is a Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 Page 12 pleasant place in which to eat. Service users appeared to eat at their own pace without being hurried and sat as long as they wished following their meal. One written comment was that a menu would be appreciated so that it was known what food was to be served. Another wrote “meals are excellent and of good variety”. Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Service users are able to make a complaint using information provided by the home and are protected by the awareness of staff of potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure in place detailing the way in which any complaint will be dealt with. There is also a complaints book accessible to all service users in which they can complain about any aspect of the service, such as the timing of afternoon tea. This record also details how these concerns have been dealt with. Pre inspection information confirmed that complaints received had been dealt with within a twenty eight day timescale. Staff spoken with were aware of how to deal with any alleged or suspected abuse and had undertaken training in the different forms of possible abuse and what to do about any suspicions they may have. Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. Service users can be assured that the home is a clean and pleasant place in which to live which is being properly maintained to provide a safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All floors of the home were seen including some bedrooms, bathroom and toilet facilities, living and dining areas and the kitchen and laundry facilities. All areas seen were to a high standard of cleanliness and free from unpleasant odours. Several comments made by people living at the home and visitors spoken with at the visit were about the high standard of cleanliness at the home. “It’s very, very clean” “we looked at a few homes: this was the best and cleanest place”. There are outside areas in which service users can sit in better weather and the gardens are maintained well. The laundry was seen and had cleanable surfaces so that good hygiene standards can be maintained, and machines were capable of washing at a temperature to control cross infection. Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Service users can be assured that they are being looked after by competent staff who are managed by a competent person though the service may be improved if staff have regular supervision, appraisal and meetings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pre inspection information about staffing levels showed that the service provides staff in sufficient levels to provide proper care for people living at the home. The home’s staff group is made up of care, kitchen, dining room and domestic staff each with different functions. Staff records were examined, which showed that written application, two written references and a face to face interview are required to enable the registered person to make a decision on whether to appoint a potential care worker. The organisation of staff records has been improved so that information can now be easily found. Criminal records disclosures were seen which were being kept as original documents. This was discussed with Mr. Mark Kelly who was advised that in line with data protection legislation, a record should be kept of the detail of criminal records disclosures and PoVA checks on a securely held list. This had been recommended at the previous inspection. Staff said that they had no written contract of employment or terms and condition of employment. There is no formal supervision or appraisal of staff Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 Page 16 at the home and there are no staff meetings, with staff being supervised informally on a day to day basis. These issues had been raised and recommended at the last inspection and is still to be progressed. Training certificates were seen in mandatory health and safety training topics, and an overall record was seen showing the training which staff had completed and which training was required. Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. Systems in place at the home ensure that the health and safety of service users is being addressed, though attention is needed to ensure that the electrical wiring at the home continues to be safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mr. John Kelly has many years’ experience as the registered provider at the home and has been joined in the day to day management and organisation by Mr. Mark Kelly, his son. Mr. John Kelly has yet to obtain a National Vocational Qualification at level 4 in management and care. Systems are in place to ensure that service users are able to raise any concern they have about their own service. A complaints book is accessible so that any service user can record any comment, and the record showed the response and any action taken to address the issues raised. A written survey of service Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 Page 18 users’ views about the service had been undertaken, and some written responses were seen. The survey responses were complimentary about the service and Mr. Mark Kelly said that further responses were expected, after which any issues raised about the quality of the service would be dealt with. Pre inspection information showed that no service user has help from the service in dealing with their financial affairs and that either a family member assists or a Power of Attorney is appointed should any service user not be able to continue dealing with their own finances. Pre inspection information showed that the home’s electrical wiring certificate was dated December 2000 (valid for five years) and was therefore out of date. The accident book was seen which needed to be replaced so that information was recorded in compliance with data protection requirements. Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 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 2 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 X X X X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 1 Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 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. 1 Standard OP38 Regulation 23(2) Requirement The fixed electrical wiring must be checked and certified as being safe. Timescale for action 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations The call bell system should be replaced with a suitable system which cannot be cancelled away from the point of call. A system for the formal supervision and appraisal of care staff should be introduced. The registered provider should consider organising regular meetings for staff at the home so that any issues can be discussed and recorded. 3 OP29 Criminal records disclosures should be maintained for six months as an original document and then should be kept as a list detailing names, the date and disclosure numbers DS0000007634.V317560.R01.S.doc Version 5.2 Page 21 2 OP26 Briar Dene in accordance with data protection requirements. Staff should be issued with a contact of employment of statement of terms and conditions in relation to their work at the home. Accident records should maintain individual confidentiality in line with data protection requirements. 3 OP38 Briar Dene DS0000007634.V317560.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V317560.R01.S.doc Version 5.2 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. 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