Inspection on 21/02/06 for Briarfield House

This inspection was carried out on 21st February 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

Briarfield House 24/04/08

Briarfield House 15/05/07

Briarfield House 05/02/07

Briarfield House 02/10/06

Briarfield House 11/04/06

Briarfield House 26/07/05

Briarfield House 29/09/04

Briarfield House 14/04/04

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

CARE HOMES FOR OLDER PEOPLE Briarfield House 8 Easson Road Redcar TS10 1HJ Lead Inspector Joanna D White Unannounced Inspection 12:10 21 February 2006 st 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 Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 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. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Briarfield House Address 8 Easson Road Redcar TS10 1HJ 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) 01642 488218 Mr Stephen Metcalf Miss Louise Metcalf Mrs P Creed Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: Briarfield House is a large detached two-storey house, built in 1902. It is a mellow building, which blends well with the surrounding properties and has an enclosed garden. The home is situated in a quiet residential road near to the racecourse. There are shops and a large supermarket within walking distance, and a nearby bus stop provides access to the town centre and sea front. The home provides accommodation for twelve elderly service users, in ten single rooms and one double room with en-suite shower, wash basin and lavatory. Bedrooms are comfortably furnished, and service users are able to personalise their rooms by bringing some possessions with them when they move into the home. Downstairs there is a bathroom/shower room, and separate lavatory and upstairs there is a bathroom and separate lavatory. There is a large spacious lounge, and a pleasant dining room, and a smokers room is provided to the rear of the house. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 21st February and commenced at 12.10 pm and concluded at 6.10 pm. Two members of staff, the registered manager, the registered provider and four residents were spoken to during the inspection. The homes policies and procedures, three care plans and two staff files were audited. The registered provider, the registered manager and staff welcomed the inspector to the home. The discussion was very helpful which took place throughout the inspection between the registered manager, the registered provider and the inspector. The registered manager and the registered provider received positively the areas, which were identified for further development. What the service does well: What has improved since the last inspection? Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 6 The statement of terms and conditions includes the current fees charged by the home. Activities are available for those residents who wish to participate. Meals are both nutritious and appetising. Pathways around the home have been repaired and are free from tripping hazards such as supermarket trolleys. The night staff numbers are sufficient to evacuate the building without external assistance. All luminaires are tested as laid down in the fire logbook, for one hour’s duration at a time. The electrical wiring has been inspected and tested and any defects remedied. Documentation to confirm this has been obtained. The registered provider has completed an annual development plan. On the day of the inspection the registered provider who spoke to the inspector provided a written report of his findings following an inspection of the care home in February. He confirmed he would send future reports directly to the Commission for Social Care Inspection. What they could do better: Residents care plans should include written information in the form of a risk assessment about how the risks, which have been identified, will be managed and minimised. Care plans should contain up to date information about how the residents’ health was promoted and maintained and the most recent date when health care services had been contacted. The residents’ health needs should be reviewed on a monthly basis. The recorded information obtained about a residents’ medication at the time of their admission should be updated and reviewed in their care plan. The staff should all receive the Department of Health’s “No Secrets” training. Effective quality assurance and quality monitoring systems should be in place to measure success in achieving the aims, objectives and statement of purpose of the home. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 7 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. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 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 the following standard(s): 6 The Home has no residents assessed and referred solely for intermediate care. This standard was therefore not inspected during this inspection. EVIDENCE: Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 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 the following standard(s): 789 The Residents health, personal and social care needs are set out in an individual plan of care. The residents’ health is promoted and maintained. The home makes sure health care services are contacted when needed. Policies and procedures were in place for the receipt, recording, storage, handling, administration and disposal of medicines. EVIDENCE: The registered manager and the registered provider who spoke to the inspector confirmed the residents’ health was promoted and maintained. Arrangements were in place for the residents to be visited in the home on a regular basis and more often if necessary from a chiropodist, dentist and optician. However some residents chose in consultation with their families, to visit their own dentist, chiropodist, or optician in the community, which was actively encouraged, by the home. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 11 On the day of the inspection a nurse was visiting the home to check residents blood pressure and to take blood samples. The staff that spoke to the inspector said they knew the residents very well and would know if there were any concerns about their emotional well-being. One resident had regular exercise. She spoke to the inspector and said she went out twice per week to visit the local shops and the market as well as going out for Sunday Lunch and to the local corner shop. All of the residents have an identified GP. Three care plans were audited by the inspector but did not contain up to date information about how the residents’ health was promoted and maintained or the most recent date when health care services had been contacted. There was also no evidence of residents health needs being reviewed on a monthly basis. The cook who spoke to the inspector said the residents received a balanced and nutritious diet. On the day of the inspection they had chicken with stuffing, mashed potato, vegetables and fruit pie and custard. A chart was kept in the kitchen a copy of which was audited by the inspector, which recorded the meals the residents had eaten. However the Care plans did not contain any details about the individual monitoring of the residents weight. The Policy and Procedures for the receipt, recording, storage, handling, administration and disposal of medicines were audited. The registered manager who spoke to the Inspector said there were no residents who were able to take responsibility for his or her own medication. Staff who spoke to the inspector on the day of the inspection said designated and appropriately trained staff administered all of the medicines. The inspector audited three care plans and although detailed information had been provided about the resident’s medication at the time of admission there was no recorded evidence that this had been updated or reviewed. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 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 the following standard(s): 13 14 The Home promotes residents contact with family friends representatives and the local community. The Residents are able to control their own lives and make informed choices about what they do and the services they receive. EVIDENCE: The registered manager who spoke to the inspector said the home had a church service, which was held the last Tuesday of every month and lasted for 30 – 40 minutes. None of the residents chose to attend the local churches. One resident who spoke to the inspector said her son and daughter visited her regularly and took her for outings in the car. Another resident said she liked to go out but recently the weather had been too cold. A member of staff who spoke to the inspector said she enjoyed taking the residents out into Redcar and playing bingo with them. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 13 The registered manager who spoke to the inspector said an activity policy had just been introduced in the home, which was audited by the inspector, and gave information about an activity afternoon taking place every Wednesday. The residents were being encouraged to speak to senior members of staff about any ideas they might have which could then be further developed. The registered manager and the registered provider told the Inspector there were no residents who handled their own financial affairs. The personal possessions of residents were agreed before their admission to the home. One of the residents who spoke to the inspector said she had brought belongings from home to furnish her room. During the inspection the Inspector saw photographs, ornaments, televisions, and residents own furniture present in their rooms. All residents and their friends had been informed how to contact external agencies e.g. an advocate who would act in their interests if this were identified to be appropriate. The inspector audited the home’s policy ‘advocacy or representation of a resident’. The Inspector audited the Homes’ access to service user file’. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Relatives are confident that a complaint would be taken seriously. Written procedures are in place, which promote the welfare of the residents. EVIDENCE: There had been one complaint regarding the home in the last twelve months. The registered provider who spoke to the inspector confirmed all complaints are taken seriously and dealt with immediately. Confirmation is sought at the six-week review following the admission of a resident that the family are aware of and know how to access the homes complaints procedure. A copy of the homes complaints procedure was displayed in the hall. The Adult Protection and Prevention of Abuse Policies and Procedures were audited and contained information about the No Secrets Protecting Vulnerable Adults Tees wide Inter agency Policy Procedures and Practice Guidance. The homes whistle blowing policy and aggression towards staff or resident-toresident was audited. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 15 Two staff files were audited and only one staff member had received No Secrets training. However the deputy manager confirmed a training course for trainers was taking place in February and staff had been identified to attend who would then cascade the training to the staff team. She also confirmed she would be providing training in the interim for her staff The staff that spoke to the Inspector confirmed they were going to receive No Secrets training. However they were aware of what action to take should they become aware of any form of abuse towards the Residents. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 16 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): These standards were not inspected during this inspection. EVIDENCE: Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 29 30 The Residents needs are met by the number and skill mix of the staff on duty. Residents are protected by the home’s recruitment procedures. Staff receive training to ensure they can meet the needs of the Residents. EVIDENCE: On the day of the inspection, the registered manager, who spoke to the inspector, confirmed a recorded staff rota was kept in the home, which showed which staff, and in what capacity, were on duty at any time during the day and night. An audit of the rota by the inspector revealed two staff members one of whom was qualified/NVQ Level 2 were on duty for the morning shift, the afternoon shift, and the evening shift. A qualified nurse and an unqualified member of staff covered the night shift. The Policy and Recruitment procedure was audited and the registered manager who spoke to the inspector confirmed this was in the process of being developed further. 60 of the care staff had achieved their NVQ Level 2 or above. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 18 Two staff files were audited; all contained the required information as stipulated in Schedule 2 of the Care Homes Regulations 2001. An Induction Book and Training record of Instruction and competence in care were audited. The following is an example of the training that had taken place: First Aid Certificate in risk assessment process and practice Fire training Emergency Aid Safe handling of medication Infection Control Personal Care Promoting independence-advocacy. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 35 The home is run in the best interests of the residents but the quality assurance systems require further development. Residents’ finances are safeguarded. EVIDENCE: The registered manager who spoke to the inspector confirmed the residents were requested to complete a yearly questionnaire about the home. However there were no other formal quality assurance systems in place. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 20 Each Resident had their own money wallet/purse/petty cash box. A record was kept of all the money a Resident received and spent. There were two signatures when money was deposited or withdrawn. The registered manager and the registered provider who spoke to the inspector said they also discussed the residents’ monies with their families. The inspector audited the Service Users Monies procedure. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X X Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 22 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 OP7 Regulation 15 Requirement The registered person must ensure residents care plans include written information in the form of a risk assessment about how the risks, which have been identified, will be managed and minimised. The registered person must ensure the residents care plan sets out in detail the action which needs to be taken by care staff to ensure the health needs of the resident are met. The registered person must ensure the residents’ care plan is reviewed by care staff in the home at least once a month, and updated to reflect the changing needs, and current objectives for health and personal care, and actioned. Timescale for action 01/08/06 2. OP7 15 01/08/06 3. OP7 15 01/08/06 4. OP8 14 The registered person must ensure the residents nutritional 30/03/06 screening is undertaken on admission and subsequently on a DS0000000079.V277220.R01.S.doc Version 5.1 Page 23 Briarfield House periodic basis, a record is maintained of nutrition including weight gain or loss and appropriate action taken. 5. OP18 12 13 The registered person must ensure all staff receives the Department of Health ‘s” No Secrets” training. Effective quality assurance and quality monitoring systems should be in place to measure success in achieving the aims, objectives and statement of purpose of the home. 01/05/06 6. OP33 24 01/08/06 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 OP31 Good Practice Recommendations The registered provider should ensure that the manager attains her National Vocational Award level 4. Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Briarfield House DS0000000079.V277220.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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