Inspection on 15/09/05 for Briarlea

This inspection was carried out on 15th September 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Briarlea 11/02/10

Briarlea 17/12/09

Briarlea 26/11/09

Briarlea 09/07/09

Briarlea 06/06/07

Briarlea 01/07/06

Briarlea 28/04/05

Briarlea 27/09/04

Briarlea 15/04/04

Briarlea 06/02/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Briarlea Badsey Road Evesham Worcestershire WR11 5PA Lead Inspector Annie OMara Unannounced 15 September 2005 12.00 pm 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. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Briarlea Address Badsey Road, Evesham, Worcestershire WR11 5PA 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) 01386 830214 Briarlea Care and Supported Living Limited Mrs Catherine Hillier Care Home 18 Category(ies) of DE(E) Dementia over 65 (18) registration, with number OP Old age (18) of places PD(E) Physical disability over 65 (18) Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28 April 2005 Brief Description of the Service: Briarlea provides residential accommodation and care for older people who may have a physical disability and/or mental health needs associated with old age.It is owned by Briarlea Care and Supported Living Limited, which is a family owned company, both directors of which are actively involved in the running of the home. The home is situated just outside Evesham in a rural area with pleasant views over the local countryside. It occupies a level site and apart from its road frontage is surrounded by orchards. The premises consist of a two storey family house, which has been extended and adapted for its current purpose. There are fourteen single bedrooms and two double. Seven of the single bedrooms have an en suite toilet. A passenger lift links the two floors of the home. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the early afternoon of a weekday. Care records were inspected as were recruitment files. Five residents were spoken to during the visit and the medication system examined. What the service does well: What has improved since the last inspection? What they could do better: The emotional and social needs of residents need to be better documented on both the assessment forms and the care plans. Nutritional and skin care risk assessments need to be introduced. Residents need to be more fully consulted about the provision of food and the choices available at all mealtimes need to be made clear to them. An activities program needs to be developed with the residents. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 6 A system of reviewing staffing levels against the dependency needs of the residents must be in place to ensure that there are always enough staff on duty. Staff must be regularly supervised and specialist training for caring for people with dementia must be introduced. All staff must receive infection control training. 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. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 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 standard(s) 1, 3, 5. Residents were assessed and provided with information about the home prior to moving in although their emotional needs were not assessed in enough detail to ensure that the home could provide an adequate service. EVIDENCE: Information was available for prospective residents and their relatives. A newly admitted resident confirmed she had been given the information before she moved in. An assessment of prospective residents was carried out prior to them moving in and this was carried out where possible when the resident first visited the home. Whilst the assessment covered all aspects of physical care the emotional and social needs of the residents were not covered in detail. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 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 standard(s) 7, 8, 9, 10. The care plans in place did not reflect all the care that was provided to residents and show that their emotional care needs were being met. EVIDENCE: There were care plans in place for all the residents and these were regularly reviewed. The social and emotional needs of the residents were not covered in detail and needed to be developed to show how staff were supporting them. There were no nutritional or skin care risk assessments in place. The medication system was managed well and a record kept of medication being received into the home and returned to the chemist. Medication sheets were signed and up to date. Medications were stored safely. Staff were observed speaking to residents appropriately and with respect. Residents spoken to felt that they were treated well by the staff and one said they were “marvellous” and “very respectful”. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 10 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, 13, 14 Residents are able to maintain contact with their families and to exercise choice in their daily lives. EVIDENCE: Residents confirmed that there were no routines in the home which were restrictive and they chose when to get up and go to bed. There were some activities arranged although all of the residents spoken to said that these were limited and that they would like more to do. This included going out more often. Visitors were made welcome in the home and were able to come when they chose. Information was available about how to contact external agencies and residents were able to bring their own possessions when they moved into the home. The service users guide needs to include information about residents’ access to their personal records. The home has introduced a menu choice sheet for residents to have a choice of meal at lunchtime. Residents said that they were able to choose any meal for their birthdays. Residents were not regularly consulted about the menus at the home although all of them spoken to felt that the food was of a good standard. Records were kept of food provided to residents. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 11 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) 18 Systems are in place to provide protection for the residents. EVIDENCE: There was a policy in place for the protection of vulnerable adults including a whistle-blowing procedure and a policy for the use of restraint. Staff were receiving training in the protection of vulnerable adults. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 12 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 The standard of the environment is good and provides the residents with a comfortable, homely place to live. EVIDENCE: A brief tour around the communal areas of the home indicated that the environment was well maintained and provided a good level of comfort for the residents. There were no outstanding issues from the environmental health officer. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 13 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, 28, 29, 30. Staff training is kept up to date. The staffing levels at times do not reflect the dependency levels of the residents and could, at times , put them at risk. EVIDENCE: The home is staffed throughout the waking day by two members of staff who are supported by domestic staff and a cook. At night there is one member of staff awake and one who sleeps in. The registered manager works in a supernumerary capacity during the weekdays. The registered manager stated that she did have the authority to have more staff on duty if the need arose. At the time of the inspection one of the residents was seen to be very frail and in need of two staff to help her to mobilise and to have personal care. In effect this would leave other residents possibly at risk with no supervision. The resident was being reassessed for another home but in the meantime the staffing levels must be reviewed to ensure the safety of all residents. A training matrix was available which showed that staff were receiving up dated health and safety training. There was limited training in the more specialised needs of the residents and none of the staff with the exception of the registered manager had received infection control training. Staff files were inspected and the registered manager confirmed that staff did not start work until they had received all the necessary checks. Personal identification was available on some files but was missing on newer files but this was because their documents had not yet been returned. Three staff have their NVQ level 3 and two have level 2. Three more staff are currently undertaking NVQ level 3 training. Induction training is undertaken by all new members of staff. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 14 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) 31, 33, 35, 36, 38. The management systems in the home ensure the safety of the residents although a formal method of review needs to be in place for its continued development. EVIDENCE: The home is managed by an experienced and qualified manager. The home invites comments from residents relatives about the standards of care provided at the home. This quality audit needs to be extended to include residents and visiting professionals. Additionally a full audit for the home needs to be developed to ensure that there is a continual cycle of review and development in the home. The policy for the management of residents finances is included in the service users guide. The home does not handle any of the residents money. Supervision has been arranged but has not yet started, although is due to start in the next few weeks. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 15 Maintenance certificates were in place for electrical safety. The fire safety risk assessment had been updated and all fire safety checks were signed for at the required frequency. There was no maintenance certificate for the electric bath hoist in place. The registered persons have employed a health and safety consultant to oversee all aspects of safety in the home. It has been identified that there are two separate fire alarm systems in operation in the home. These will be replaced by one system when the home is extended in the near future. Accident records were filled in but there was no monthly audit in place. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 16 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 3 x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 x 2 x 3 2 x 2 Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 17 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 3 Regulation 14 Requirement The written assessment must contain information regarding the emotional and social needs of the residents. Timescale of 31st October 2004 and 31st May 2005 not met. The residents care plans must include all aspects of care and in particular the emotional and social needs of the residents. Timescale of 31st October 2004 and 31st May 2005 not met. The residents care plans must include risk assessments for nutritional and skin care. An activities program must be provided after consultation with the residents. Staffing levels must be reviewed and increased as necessary in line with the dependency levels of the residents. All staff must receive infection control training. All staff must receive training in dementia care. A quality assurance program must be introduced in the home to meet with the requirements of E52 S45857 BRIARLEA V246020 150905.doc Timescale for action Immediate and ongoing 2. 7 15 Immediate and ongoing 3. 4. 5. 8 12 27 13 16(2) 18(1) 31st October 2005 31st October 2005 Immediate and ongoing 30th November 2005 31st December 2005 31st December 2005 Page 18 6. 7. 8. 27 27 33 18(1) 18(1) 24 Briarlea Version 1.40 9. 10. 36 38 18(1) 13 Regulation 24 and Standard 33. Timescale of 31st December 2005 not met. All staff must receive regular supervision. A maintenance certificate must be in place for the electrical bath hoist. 31st October 2005 31st October 2005 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. 3. Refer to Standard 14 15 38 Good Practice Recommendations Information should be provided to residents about their access to personal records. Residents should be regularly consulted about the menus provided in the home. Accidents should be regularly audited. Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 19 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcestershire WR3 7NW 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 Briarlea E52 S45857 BRIARLEA V246020 150905.doc Version 1.40 Page 20 - 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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