Inspection on 07/09/05 for Briar Hill House

This inspection was carried out on 7th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Hill House 24/06/09

Briar Hill House 30/05/07

Briar Hill House 21/02/06

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Radbrook Nursing Home

The Conifers Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Briar Hill House 51 Attlee Crescent Rugeley Staffordshire WS15 1BP Lead Inspector Joanna Wooller Announced 7 September 2005 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 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 Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Briar Hill House Address 51 Attlee Crescent Rugeley Staffordshire WS15 1BP 01332 296200 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Methodist Homes for the Aged Mrs Pauline Kincaid CRH 28 Category(ies) of PD - 28 registration, with number PD(E) - 28 of places Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 28 PD- Minimum age 60 years on admission One PD Service user- Minimum age 44 years on admission Date of last inspection 08/03/05 Brief Description of the Service: Briar Hill House was purpose built in 1992. It is situated close to Rugeley Town centre. This 28 bedded home is presently owned by Methodist Homes. The Manager Mrs Kincaid has been in post for many years and has a wealth of knowledge and experience in elderly care, she is supported by her Deputy Manager. The home is divided on two identical levels and each floor has 14 bedrooms, a large lounge, a spacious dining room and an individual kitchenette. All bedrooms are single occupancy and have ensuite facilities, which include WC, sink and a walk in shower. Seven of the bedrooms have separate adjoining lounge areas for the use of the service user and their families. A variety of specialist equipment was available for the service users who require assistance. The home has a beautiful garden, which is accessible to all service users. There is a water feature and summerhouse sited in the grounds. The home has its own hairdressing salon/relaxation room. Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine announced visit was made on the 7th September 2005 @ 09.15hrs. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including pre and fieldwork, amounted to 7hrs. The registered care manager was in the home accompanied by her deputy manager, two trained nurses and five care assistants. The ancillary staff on duty included; a cook, two housekeepers, one laundress, the administrator, and the activity organiser. The maintenance person is contracted to the home. The staffing levels inspected were appropriate to meet the needs of the current 26 service users in the home. The inspection included the following elements; A tour of the building, Observation and inspection of records relating to the provision of care, A discussion with several service users, Discussions with staff members on duty, Careful observation and sampling of other services provided such as catering and laundry, And an inspection of the managerial aspects such as staffing issues, quality assurance and health & safety. Since the last inspection on 8th March 2005; there had been no changes to the management of the home, one complaint had been received and no additional visits had been necessitated. It was evident to the inspector that all aspects of care had been well addressed, with service users able to choose the home following an assessment and invitation to visit the home. Service user plans had been well written and demonstrated that health, personal and social care needs had been met and well documented. Privacy, dignity and choice aspects for service users were being upheld. Only one complaint had been received since the last inspection, and policies and procedures seen covered these issues. No incidents or reports of abuse of any kind had been reported. The home was found to be fit for purpose and provided a safe environment for the service users and staff. A very homely atmosphere had been created, and the premised were clean and tidy. Adequate areas for service users were Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 Page 6 provided including; well positioned communal space, attractive dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities, including catering and laundry, were adequately provided. Health and safety aspects had been given a high priority and no shortfalls were noted. A maintenance file provided to the inspector allowed close inspection of service plans and maintenance contracts. Recruitment and retention of staff aspects were very good with little/no staff turnover. Staff training had been given a high priority, with induction training being followed by NVQ training, and staff had received regular supervision. 100 of staff were NVQ Level 2 trained and they also held the First aid certificate and food handling qualification. The home was exceptionally well managed by Mrs kincaid, a qualified and competent care manager. General management aspects were good with quality assurance taking place. Records had been correctly filed and stored. Assurances were given regarding the positive financial viability of the home, and that suitable accounting/business procedures are adopted. What the service does well: What has improved since the last inspection? A new nurse call system has been fitted along with cordless telephones of the benefit of the staff and service users. A deputy manager has been employed to support the manager in her role. 100 of staff are NVQ 2 trained and also 100 of staff are first aid trained and hold the food hygiene certificate. Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 Page 7 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 Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 Page 9 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 standard(s) 1 to 5 All service users are admitted to the home following a pre admission assessment and confirmation that their individual assessed needs can be met whilst in the home. EVIDENCE: Each service user is individually assessed prior to admission and this was evidenced within the care records seen at the visit. Prospective service users and their relatives are able to visit the home at any time to ensure they are making the right choice for their new home. The statement of purpose and informative service user guide assists the service users to make the right choice. Those service users spoken to had been supported by their families in choosing the home. Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 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 standard(s) 7 to 11 Service users individual health, personal and social care needs are all set in individual care records which were well documented and reviewed monthly. Robust policies and procedures are in place at the home with regard to record keeping and medication administration. EVIDENCE: Each service user has an individual care record, which was evidenced as being well written, informative and updated monthly. Personal details were documented and monitored as being met. Named nurses have responsibilities to each of their service users and the relevant care records. Care audits were evident within the care records completed by the manager. Specialist nurses are welcomed in to the home to support the nurses in meeting the service users needs, and there was evidence of their involvement. The home is supported by local GP’s and Pharmacy services. Policies and procedures promote good practice of administration of medication and no issues were raised relating to medicines. Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 Page 11 There was evidence that service users were treated with respect and their privacy upheld by the interaction of staff. Staff were seen knocking on bedroom doors prior to entering. Service users are assured by the manager and the staff that at the time of their death they and their family will be treated with respect and sensitivity. There was a wealth of thank you letters and appreciation cards which had been sent to the staff. Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 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 standard(s) 12 and 15 Service users are encouraged to maintain contact with all family, friends and community links whilst in the home. Wholesome and appealing meals are cooked in the home and service users benefit from exercising choice and preferences, which are documented. EVIDENCE: A monthly events poster is displayed around the home, for service users and their families to be involved in social activities. The service users benefit from the input of the homes activity coordinator. She excels herself in the art of social care and recreational activities for all the service users. Service users spoken to enjoy the input and say the balance is just right. During the inspection visit many service users were enjoying a reminiscence music session. Notice boards were evident throughout the home with events photographs and thank you letters. Visitors are welcome at any reasonable time and visitors were evident during the visit. Those spoken to said they felt content with the care that their relatives received and they always felt welcome on arrival to the home. Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 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 standard(s) 16 to 18 A robust policy and procedure is evident throughout the home to deal with complaints and concerns. Relatives and service users felt able to raise concerns with confidence that it would be dealt with promptly. EVIDENCE: The complaints procedure is evident throughout the home and within the statement of purpose and service user guide. One complaint had been received by the CSCI since the last inspection and this had been dealt with and rectified. Legal rights of service users are protected, and preferences are documented within their individual files. Service users felt that the professional staff protected them from abuse by their endearing manner and genuine interest in looking after the older person. Staff had received training in identifying abuse and reporting it. All staff receive instruction on whistle blowing on induction to the home and this is revisited through staff meetings and supervision. Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 22 and 26. The service users do live in a clean, safe and well-maintained environment. Specialist equipment to assist individuals is available as required. EVIDENCE: The environment of the home was found to be exceptionally clean, hygienic and tidy in all areas inspected. The home had evidenced that it is well maintained, with an excellent maintenance folder of records available to demonstrate this. Each service user is able to personalise their bedroom as they so wished and there was evidence that this is appreciated. Specialist equipment is evident in the home and within the maintenance folder as being well maintained. Pressure relieving mattresses in varying forms are on each bed in the home. A mattress audit is undertaken at least annually. Independence is encouraged and promoted throughout the day with assistance given as required. Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 Page 15 Communal areas are light and airy with varying seating arrangements. The dining areas are also in a designated area; tables are laid with cloths and flowers that are appealing to the eye. A new nurse call system had recently been fitted in all service users areas and this was seen as a big improvement, along with the cordless telephone system which had also been recently installed. Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 to 30 Service users needs are being met by the carefully recruited staff that are suitably trained and professional in their manner. EVIDENCE: Staffing levels are monitored to ensure that the needs of the service users can be met. Staffing rota’s were made available for the inspector as evidence of staffing levels and staff competence. All staff is first aid trained and have a food hygiene qualification. 100 of care staff is NVQ 2 trained and further training to NVQ level 3 is promoted. Two to three trained nurses are on duty for each shift, supported by care staff. Each trained nurse has a responsibility to a specialist subject such as continence and wound care. This link nurse role promotes current good practice within the home. A robust recruitment procedure is in place, which demonstrates the managers’ commitment to employing and developing highly qualified and professional staff. Staff training is recorded and monitored and was evidenced as appropriate to the care setting. The home benefits from a bank of staff to cover sickness and holidays and no agency staff are employed. Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 38 The home is run and managed for the benefit of the service users. Staff are suitably supervised and they and the service users are safeguarded by the policies and procedures in home. The health, safety and welfare of service users and staff is promoted. EVIDENCE: It was evident whilst in the home that the home is run in the interest of the service users. Staff and relatives confirmed that the service users wishes and choices are promoted within the home. Service users spoken to felt that they felt secure in the home and they belonged there. Financial issues were all satisfactory and policies and procedures protected service users financial interests. Th3e ethos and leadership within the home is positive and open. The manager and her team are highly thought of by service users and their relatives/representatives. Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 Page 18 Staff supervision is in place with neat documentation and relevant matters being addressed. The health, safety and welfare of staff and service users is promoted `and protected by the rigorous testing, recording and monitoring of systems within the home. The maintenance person maintains the home in a professional manner and the records seen by the inspector evidence this. Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 4 4 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 4 COMPLAINTS AND PROTECTION 4 4 x 3 x x x 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 4 4 4 x x 4 x 4 x x 4 Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 Page 20 Are there any outstanding requirements from the last inspection? 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 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 Good Practice Recommendations Briar Hill House E51-E09 S22317 Briar Hill V241752 070905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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