Inspection on 11/06/07 for Briardene Care Home

This inspection was carried out on 11th June 2007.

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

Briardene Care Home 30/06/09

Briardene Care Home 03/06/09

Briardene Care Home 01/05/09

Briardene Care Home 16/02/09

Briardene Care Home 16/09/08

Briardene Care Home 08/06/06

Briardene Care Home 06/09/05

Briardene Care Home 14/12/04

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

CARE HOMES FOR OLDER PEOPLE Briardene Care Home Newbiggin Lane Westerhope Newcastle upon Tyne NE5 1NA Lead Inspector Ian Armstrong Key Unannounced Inspection 11th June 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Briardene Care Home DS0000060363.V338237.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. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Briardene Care Home Address Newbiggin Lane Westerhope Newcastle upon Tyne NE5 1NA 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) 0191 286 3212 0191 286 6820 Windmill Hills Ltd Ms Audrey Margaret Alderson Care Home 59 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (28) of places Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 8th June 2006 Brief Description of the Service: Briardene is a care home with nursing providing care for older people with physical and mental health needs. The home is owned and managed by Windmill hills Limited that is part of a larger group, which provides care services for a variety of client groups. The home is staffed by registered general nurses supported by care staff. The philosophy of care is to support the residents in their activities of daily living and to provide for their physical and mental health needs. The home is situated in Newbiggin Lane in the west of the city of Newcastle upon Tyne fairly close to local shops and public transport links. The building is comprised of three floors, the top floor being staff accommodation. The lower two floors are resident accommodation with 62 single bedrooms all with ensuite facilities. On each of these floors there are a number of bathrooms, toilets, lounge and dining rooms. The home has a visitor coffee room and hairdressing room. There is also a kitchen and laundry room. To the rear of the home there is a very nice garden and patio area. Fees in the home are £373 to £589 this does not include hairdressing and toiletries. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on (date). • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 11/06/07 During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager/provider what we found. What the service does well: The décor and maintenance of the building is good. This provides residents with a comfortable setting in which to live. The way the service recruits new staff is very good and ensures that residents are not at risk from harm. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Briardene Care Home DS0000060363.V338237.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 Briardene Care Home DS0000060363.V338237.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): Quality in this outcome area is good. 3 & 6. This judgement has been made using available evidence including a visit to this service. Comprehensive assessments are carried out before and after admission to ensure that people’s needs can be planned and properly met. Detailed information is available to help people make choices about the service before moving in. The home does not provide intermediate care. EVIDENCE: Assessment records were completed to a satisfactory standard but do not include the gender of staff for personal care tasks. Relatives spoken to said that the home provided them with good information on which to make a decision about moving there. Copies of the service user guide, statement of purpose and complaints policy had been given. Each of the residents had a Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 9 written contract in their files, which described the conditions of their stay in the home and the period of notice by both parties these were well written. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of care planning is good as it provides the right level of information to staff to fully support meeting residents needs. Care is planned with residents in a sensitive manner. Healthcare needs are well met by using a multi-agency approach. This helps residents to stay healthy. Adequate medication systems are in place to make sure that residents are not put at risk. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 11 EVIDENCE: Assessments information informs the care planning process by assessing people’s various needs such as, continence, nutritional, pressure care, social, psychological and risk these assessments. These records were regularly evaluated and updated. Care plans were well written providing for a range of care needs, monthly evaluations of these were being carried out. Social care plans however are at present too generalised and need to better address each individuals needs. Formal review meetings take place to review the care needs of individuals, with the resident and/or family and other agencies involved in the care are invited. Relatives spoken to said they were involved and consulted about the care records. Records of visiting professionals were comprehensively completed and the records showed that residents health care needs were being regularly assessed and met. A podiatrist who was in the home at the time of the visit was spoken to she said the home had provided her with good information about the residents who had been referred to her. She believed services for residents in the home to be good. The systems for the receipt, administration, storage and disposal of medications were all checked and were satisfactory. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples lifestyle experiences in the home at the present time are quite poor. Residents have little opportunity to take part in a variety of leisure pursuits and interests. Mealtimes are flexible to suit individual preferences and lifestyles. Residents are given a fair degree of choice and are supported to eat meals where they have specific needs. EVIDENCE: The homes activities coordinator has been off sick for a number of weeks and the homes manager agreed that activies for residents had suffered because of this. Therefore, there has been very few planned activities and the weekly activities programme has not been carried out during this time. Relatives spoken to said also that there was very little for the residents to do. A resident said that ‘’the days were long with little stimulation’’. There has been no trips Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 13 out for residents for a long time. A local vicar visits the home every two weeks and a priest every month, but no services are held in the home. However, one resident goes to church each week. Some events, which have been held in the home since the last visit include, a film show, pie and pea supper, clothes party. Queens’s birthday celebration party. A singer/entertainer also visits the home every two months relatives said the residents enjoy these events. Staff in the home generally respect residents wishes what clothes to wear each day, food likes dislikes are identified and met however gender of staff for personal care tasks also needs to be identified and met. The lunchtime meal was observed the dining tables were set with tablecloths and centrepieces however there was no condiments on the tables, the meal was pork casserole with potatoes carrots and peas or cold chicken with salad, sweet was coconut sponge with custard or yoghurt or ice cream. Staff who were present served residents with portion sizes based on their knowledge of residents eating preferences which was good to see. Good interactions between staff and residents were observed. Residents and relatives spoken to say the food in the home was generally good. Menus were seen these generally showed a good choice and variety of food being provided. However breakfast meals should state what is being cooked each day also sandwiches must state their ingredients. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints procedure is in place and clearly displayed to ensure that complaints are dealt with effectively and to the satisfaction of the complainant. Clear protection procedures are in place to protect residents from risk of harm. EVIDENCE: The homes complaints policy and safeguarding procedures (locally referred to as POVA) are comprehensive and staff in the home spoken to are aware of the procedures to follow. Relatives spoken to said they had been given copies of the complaints procedure and said if they had any concerns they believed the manager would deal with them appropriately. Since the last inspection there has been three complaints all have been responded to correctly and as a result of one of these, changes to the laundry service have been made. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building is clean and generally well maintained it provides a comfortable setting for residents to enjoy. EVIDENCE: A number of bedrooms were visited these were decorated according to personal taste and highly personalised with residents own furniture and effects. The kitchen area was seen and was very clean and tidy good stocks of food were in evidence, kitchen-cleaning records were read and are being well maintained. The door to the rear of the kitchen doesn’t have a fly screen, which could create problems around food hygiene. The laundry room was also clean and tidy and COSHH information was being displayed. The standard of decoration and furnishings in the home is good and creates a comfortable and Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 16 homely environment for people to live in. One or two bathrooms and toilets were seen these were also clean and tidy the bath water temperature was tested in one bathroom and was within the accepted range. There was no obvious smells or odours in the building and it was very clean and tidy throughout. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are in post to meet the diverse needs of residents. Opportunities for training are good. This enables staff to learn new skills to better support residents in all aspects of their lives. Robust recruitment procedures are in place, which help to prevent risk of harm to residents. EVIDENCE: Duty rosters were inspected these showed that adequate numbers of staff are being deployed in the home each day and are being maintained. Staff on duty on the day of the inspection were in line with those rostered. The following staffing arrangements apply each day; am: 1 Qualified, I Senior Carer, 10 care staff. pm: 1 Qualified, 1 Senior Carer 8 care staff, night duty: 1 Qualified 1 Senior carer 4 care staff. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 18 Two recently recruited staff files had all the appropriate checks in place and were completed to a good standard. Staff training records were checked these were of a good standard. Statutory and client centred training were being achieved. Staff spoken to said they were satisfied with the levels of training they had received. Relatives said that staff were knowledgeable and were meeting the resident’s needs. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 19 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, & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager in the home has an open style and is clearly present in the home to give direction and support to staff. Quality assurance systems are in place but are still being developed. This will help to shape the quality of the service and ensure it is run in the best interests of the residents. Good systems and practises are generally in place that helps to ensure that residents and staff are safe from risk of harm. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager of the home is an experienced practitioner she completed the Registered Manager Award in February 2007. Prior to managing Briardene she managed another company home. Staff said she was approachable for advice and support. Staff and relative are meetings minuted and had appropriate agendas with evidence of actions being taken when issues were identified to bring about improvement. However, the frequency of these meetings at the present time is inadequate and they need to occur on a more regular basis. Relative questionnaires were last sent out in February 07 responses from these were in the main very positive about the homes services. Residents personal allowance monies two of these were checked there was evidence of regular transactions taking place with two staff signatories for all transactions. A clear audit trail could be followed money balances were correct. The homes accident book records were seen the manager carries out regular audits of these the records were satisfactory. The fire logbook records were satisfactory for all checks and drills however in-house instructions to staff are not being carried out at the specified frequency and could compromise safety. Utility records were inspected all of these were satisfactory and up to date. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 21 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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 4 X 4 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes. Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 23 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 23.4(d) Requirement The Registered person must ensure that all staff receives inhouse fire instructions in line with those specified in the fire logbook. Outstanding since 060905 The Commission must be informed when this has been been completed. 2. OP7 15 The Registered person must ensure that social care plans are written for each resident that meets their individual needs. The home must provide a weekly programme of activities for the residents that take into account individual lifestyles and preferences. 31/08/07 Timescale for action 15/07/07 3. OP12 16.2 (m&n) 31/07/07 Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 24 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 OP33 Good Practice Recommendations Relative and staff meetings need to take place more regularly to ensure that the service provided continues to be satisfactory. Menus in the home need to state what is being offered for cooked breakfast each day and sandwich ingredients need to be specified. 2. OP15 Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Briardene Care Home DS0000060363.V338237.R01.S.doc Version 5.2 Page 26 - 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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