CARE HOMES FOR OLDER PEOPLE
Briardene Care Home Newbiggin Lane Westerhope Newcastle upon Tyne NE5 1NA Lead Inspector
Mary Blake Unannounced Inspection 8th June 2006 09:00 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.V299864.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.V299864.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 Vacant 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.V299864.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th September 2005 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 en-suite 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. Briardene Care Home DS0000060363.V299864.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over one day and involved two inspectors. All of the key standards have been assessed during this visit and from other information provided to the Commission. Fifteen residents and twelve staff (nurses, carers and ancillary) were spoken to. Others were chatted to briefly. Seven relatives were spoken to during the visits. The regional and operational managers of the company were available during this inspection. The views of a visiting GP were also sought. Eight care plans, training records and records for medication were examined. Staff files, training records and health and safety documentation were looked at. What the service does well:
The staff have a good understanding of residents individual needs. The residents and relatives were very complimentary about the staff. For example “the staff are very kind” “they never mind helping” “they give you time” “ I have improved so much since I came here” Staff were kind and considerate when helping residents. Residents explained the admission process; this includes a gradual introduction to the home and a detailed pre-admission assessment. This helps new residents adjust and settle into living in the home. Relatives were also very positive about the care and support provided. The home and staff create a positive atmosphere, which residents commented upon and which is welcoming to families and visitors. The home has strong links with supporting health professionals, which will give good health support to residents. The home is very clean, well decorated and furnished to a good standard. The quality assurance system is comprehensive and it was evident that the area manager has a high profile within the home, she had a good knowledge of the home, residents and staff needs and residents/families were aware of her role and responsibilities, which they felt particularly important when the home had no manager. Briardene Care Home DS0000060363.V299864.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. Briardene Care Home DS0000060363.V299864.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.V299864.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Briardene does not provide intermediate care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Satisfactory pre-admission assessments are undertaken but this is not always reflected in the care plan. EVIDENCE: Pre admission assessments are obtained from other professionals such as social workers, psychiatrists and health. The home completes their own assessment. The care plans must consistently reflect all the assessed needs. A recent admission to the home said he was able to visit and meet staff and the felt he and his family were involved throughout. The family were particularly positive about the support he was, and is, given to re-establish his confidence and gain independence. Briardene Care Home DS0000060363.V299864.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and social care needs of service users are being met but the records that support this care must improve. Residents are generally protected by the homes policies and procedures for dealing with medicines, but administration records must improve. Residents feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Eight care plans were examined and there is an inconsistency to the amount of information, which is recorded. The assessment tools such as pressure care, nutrition, moving and handling, mental health and dependency are not completed consistently. Care plans are based on activities of daily living but not all the needs are identified such as social care plans. Periodic evaluations are inconsistent.
Briardene Care Home DS0000060363.V299864.R01.S.doc Version 5.2 Page 10 Care plans do not reflect personalise care they appear to be generalised. Staff did not refer to them and described caring for people in the same way. Contact with social and health professionals is good and there were a number of professional visitors throughout the day including GP. McMillan Nurse, Physiotherapist, Speech Therapist and Chiropodist. The new manager and the Company have already taken steps to improve the care planning arrangements. Training is planned and records reviewed. There was evidence in the care plans of auditing by management. The medicines in the home are generally well managed and safely disposed. The treatment room was tidy. There were a number of unsigned boxes within the administration record for several residents, some drugs stored loosely and unnamed. A recent internal audit had identified similar issue and steps are being taken to address them. The controlled drugs were audited and were satisfactory. Visitors and residents feel that they are treated well and their privacy is respected. ‘I can close my door and the staff are good.’ PB (resident) Residents were observed to use the telephone and one person received a call from her daughter abroad with help from staff. All health visitors were taken to people’s bedrooms for private consultation. Briardene Care Home DS0000060363.V299864.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 at least once during a 12 month period. 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. Resident’s social needs are not being met fully and the home is addressing this. Residents maintain contact with family/friends/representatives and the local community as they wish. Residents are helped to exercise choice and control over their lives but this is not evidenced in care plans. Residents receive a wholesome appealing balanced diet but the surroundings must improve. EVIDENCE: The home has a new activities co-ordinator who is very committed and enthusiastic. A good rapport between residents and the activities person was observed on the first floor. Residents were enjoying listening to music; one person was dancing another singing. People like to go outside in the beautiful garden. The management have agreed that the activities co-ordinator will work solely on activities rather than 50:50 care and activity. This is to ensure that
Briardene Care Home DS0000060363.V299864.R01.S.doc Version 5.2 Page 12 residents have the full opportunity to access activities, which they personally will enjoy. The inspector provided the activities co-ordinator with further advice on activities for people with dementia from Dementia North. Visitors were observed to come and go throughout the day. Staff have a good rapport with relatives. Relatives felt positive about the staff and being made welcome when they visit. They did share concerns about the unsettled management arrangements. Service users handle their finances for as long as they can. People are able and encouraged to bring their own possessions and keepsakes from home and this was evident in resident’s bedrooms. Care plans do not reflect the choices, which are supported, and there is no evidence of service users involvement in their care plans or relatives. The menus have been updated and good information is available for resident’s choice. The lunchtime arrangements were observed on both floors. The majority of the dining tables did not have a tablecloth or condiments such as salt and pepper. Staff were attentive to residents and assistance was given to eat if required. People were given the choices on the menu, which was liver and onions or shepherds pie. Fresh fruit and cold drinks were served on a hot day. One visitor praised the food and choices. ‘X enjoys porridge.’ Other comments included ‘I like my food’ ‘I get plenty’ ‘Oh lovely fruit.’ Briardene Care Home DS0000060363.V299864.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives and friends are confident that their complaints will be listened to, and acted upon. Residents are protected from abuse but all staff must be trained. EVIDENCE: The home has a complaints policy and staff are clear about the procedure to deal with complaints. Residents and visitors said that they knew who to talk to if they were unhappy and had confidence that these would be dealt with. The company also has a high profile within the home. The complaints record was not available for inspection. The home has a Protection of Vulnerable Adults (POVA) procedure, which complies with the Department of Health ‘No Secrets’ Guidance. Not all of the staff in the home are aware of POVA and Whistle blowing procedures or received training this may compromise residents safety. Briardene Care Home DS0000060363.V299864.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 at least once during a 12 month period. 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. Residents live in a safe well-maintained environment. Residents live in safe, comfortable bedrooms with their own possessions around them. The home is clean, pleasant and hygienic. EVIDENCE: The communal areas of the home are well decorated maintained and clean. A number of resident’s bedrooms were seen these were in the main nicely personalised with lots of personal possessions. Briardene Care Home DS0000060363.V299864.R01.S.doc Version 5.2 Page 15 Those parts of the home that were seen were clean and hygienic with no obvious smells or odours. On the first floor changes have been made to the dining arrangements and reducing the congestion in the corridor, which distresses residents. Both floors were relaxed and homely. The garden areas are well cared for and involve residents; these were well used by residents and their visitors. Briardene Care Home DS0000060363.V299864.R01.S.doc Version 5.2 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 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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the number and skill mix of staff and are protected by the homes recruitment policy and practices. The staff team are trained and appeared competent but records were not available to support this. EVIDENCE: Staffing rota and observation during the day indicated that the home is well staffed. The Ground floor has 1RGN and 4 carers, First Floor 1 Senior care and 4 carers. There is good ancillary support. Four staff recruitment files, across all grades, were inspected and were satisfactory. Training files examined did not clearly detail what training staff had completed for induction, foundation, mandatory and NVQ training. There was variation from staff responses on training completed, some had completed a wide range others had none. Briardene Care Home DS0000060363.V299864.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of residents. Resident’s financial interests are safeguarded but one area must improve. Staff are not always appropriately supervised. The health, safety and welfare of residents and staff are generally and protected. EVIDENCE: Briardene has not had a registered manager for some time but Mrs Audrey Alderson is now the proposed manager. Good quality assurance arrangements are in place. The Company representative completes monthly visits and reports. It was evident that the
Briardene Care Home DS0000060363.V299864.R01.S.doc Version 5.2 Page 18 homes line manager is well known to residents, family and staff and she knows them personally. Relative and staff meetings have recommenced. The Company have corresponded with families during the uncertain management period. The Administration Manager, Pharmacist and Property management, periodically undertake quality audits. The Operations Manager is reviewing policy and procedures. Resident monies records were checked; there was evidence of regular personal expenditures, with two staff signatories for all transactions. Money balances were checked and found to be correct. Receipts were not available for some expenditure. Staff supervision on a 1:1 basis has not occurred due to the management situation. The new manager now intends to reintroduce this with staff. The maintenance and servicing records are in place. The Fire Log book did not have up to date emergency lighting and alarm panel checks records. The fire alarm was checked during the inspection. Level of in-house fire instruction for staff was still found to be unsatisfactory, although staff have received recent fire drills, this could compromise the safety of residents. Briardene Care Home DS0000060363.V299864.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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 2 2 2 Briardene Care Home DS0000060363.V299864.R01.S.doc Version 5.2 Page 20 Yes 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 OP38 Regulation 23.4(d) Requirement The Registered person must ensure that all staff receive inhouse fire instructions in line with those specified in the fire log book. Outstanding since 060905 The Registered person must ensure that care plans assess and identify all the needs of service users, provide actions and timescales, are periodically evaluated and consistently completed. The Registered person must ensure that care plans reflect the choices given to service users and involve service users /representatives. The Registered person must ensure that medication administration records are completed at all times. The Registered person must ensure that all staff receive POVA training The Registered person must provide CSCI with a training programme; this must include induction, foundation,
DS0000060363.V299864.R01.S.doc Timescale for action 01/07/06 2. OP7 15 30/09/06 3. OP14 15 30/09/06 4. OP9 13(2) 09/06/06 5. 6. OP18 OP30 13(6) 18 (1) 30/09/06 01/08/06 Briardene Care Home Version 5.2 Page 21 7. 9. OP34 OP36 17 schedule 4 18 (2) mandatory, NVQ and other training and dates completed. The Registered person must make receipts available for all resident’s expenditure items. The Registered person must ensure that all staff receive supervision at least 6 times a year 09/06/06 30/09/06 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. 2 Refer to Standard OP12 OP15 Good Practice Recommendations The weekly activities programme could be further developed to provide a greater variety of activities. The layout of the dining rooms and use of table clothes should be considered. Briardene Care Home DS0000060363.V299864.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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