Inspection on 06/06/07 for Briarlea

This inspection was carried out on 6th 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 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

Briarlea 11/02/10

Briarlea 17/12/09

Briarlea 26/11/09

Briarlea 09/07/09

Briarlea 01/07/06

Briarlea 15/09/05

Briarlea 28/04/05

Briarlea 27/09/04

Briarlea 15/04/04

Briarlea 06/02/04

Similar services:

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 7PA Lead Inspector Yvonne South Unannounced Inspection 6th June 2007 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 Briarlea DS0000045857.V335748.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. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Briarlea Address Badsey Road Evesham Worcestershire WR11 7PA 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) 01386 830214 Briarlea Care and Supported Living Limited Mrs Catherine Hillier Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18), of places Physical disability over 65 years of age (18) Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st July 2006 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 a level garden and orchards. The premises consist of a two-storey house. There are fourteen single bedrooms and two double rooms. Seven of the single bedrooms have en suite toilets. A passenger lift links the two floors of the home. There are two communal lounges and a conservatory, a dining room, two communal bathrooms and communal toilets. A copy of the Statement of Purpose and inspection reports were available in the entrance to the home. People could be provided with copies if they wished and were also referred to the internet as a source of inspection reports. On 13.07.06 the registered provider stated in the pre inspection questionnaire that the current charges were between £1400 and £1660 per month. Additional charges were made for hairdressing; £5 - £25 and chiropody; £12 £15. Newspapers were paid for directly to the supplier. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that incorporated information received by the Commission for Social Care Inspection since the previous inspection, which took place on 01.07.06, and the information obtained during fieldwork on 06.06.07. The fieldwork took place over eight hours, during which the inspector spoke to four residents and two staff. Documents were assessed and a partial tour of the premises was also undertaken. The registered manager gave assistance. Prior to the fieldwork the home was asked by the CSCI to complete and return a pre-inspection questionnaire and to distribute questionnaires to the residents and health care professionals seeking their opinions of the service. To date four responses have been received from residents, two from health care professionals and two from relatives. The focus of this inspection was on the key National Minimum Standards and requirements that arose out of the previous inspection. What the service does well: What has improved since the last inspection? Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 6 Since the last inspection suitable storage had been obtained for the storage of controlled drugs and the hoist had been serviced. This has improved safety for residents in both areas. Some bedrooms have been redecorated. 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. Briarlea DS0000045857.V335748.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 Briarlea DS0000045857.V335748.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): 3, (An intermediate service is not provided therefore standard 6 has not been assessed.) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information and support they need to help them make a decision regarding their admission to the home. Needs are assessed prior to admission to ensure places are only offered to those whose needs can be met by the service. EVIDENCE: It was observed that there was an up to date Statement of Purpose and Service Users’ Guide readily available. The residents’ questionnaire responses indicated that they considered they had received all the information they had needed to help them make a decision regarding admission to the home. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 9 The care of two residents was assessed and the documents demonstrated that someone from the home had undertaken an assessment of care needs before a place was offered. Although the format included prompts for all the topics listed in standard 3.3 the answers were limited and contained very little personal information on which to build an initial care plan. It was recommended that more informative answers were sought and recorded. None the less the residents in the home and the questionnaires they returned indicated that they believed their needs were being met. Briarlea DS0000045857.V335748.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. Staff have the information and guidance they need so that the residents’ social and health care needs are met. EVIDENCE: The documents demonstrated that risk assessments had been undertaken and care plans had been drawn up describing how needs were to be met. However the care plan for a person recently admitted to the home had not been developed, as more information became known. Some care plans needed further development for example more information was needed regarding sight, hearing and diabetes. Base line assessments needed to be made as soon as possible after admission on all topics including pressure care and nutrition. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 11 Risk assessments and care plans had been regularly reviewed. The daily records were well maintained and informative. They indicated that there were good links with other health care professionals and this view was supported by the activities and communications that took place during the fieldwork. A relative said in the questionnaire response; ‘I feel my mother is being well looked after with her diet and medication since she has been at Briarlea. I feel her health has improved.’ There was little evidence that the residents or their relatives had been consulted and involved in drawing up their care plans and there was no information regarding the residents’ wishes relating to their care at the end of their lives. Medication was well managed. The records indicated that staff had received appropriate training and they confirmed this. Sample signature and initial lists were available and records were well maintained. The daily records indicated that responses to medication were monitored and responded to. Medication administration sheets were well maintained and storage was secure, clean and suitably maintained. Key security was good. Briarlea DS0000045857.V335748.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 good. This judgement has been made using available evidence including a visit to this service. A wide range of activities is provided so that residents have interests and stimulation they can pursue. They are offered varied nutritional meals so they can choose food they enjoy. Support is provided for those who wish to attend religious services and links with the community are maintained. EVIDENCE: The home had a lively activities programme. This was changed every month and residents were able to choose whether or not to participate in a wide range of events. Entertainers were hired to visit the home and on the day of the fieldwork everyone enjoyed the music and antics of two magicians. Three residents in a lounge said that they enjoyed living in the home, as they were free to do what they pleased and there was lots going on. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 13 Another resident said that he enjoyed the visits made by the local vicar and gained comfort from being able to take Holy Communion each month. It was observed that the planned activity for the day and the menu for the day were both displayed. The residents confirmed that they made their own decisions regarding their lives as far as they were able. They were observed to be walking around the home and to and from their bedrooms as they wished. The food was said to be very good. One resident said in the questionnaire that the breakfasts could be more varied. Another commented that the food was very good and he was putting on weight he was so content. The sample of menus demonstrated that a choice of nutritional meals was not offered for every meal but the residents said that there was ‘always something else they could have if they wanted’. Good information was available in the kitchen regarding residents’ likes and dislikes and there were alert triggers for staff for individual residents’ particular needs and allergies. A record of food provided was maintained and there was evidence that residents had made choices regarding their meals. The care records demonstrated that information was available regarding the individual’s interests and participation in events, their likes and dislikes regarding food as well as their dietary needs and their religious needs should they have any. There was an open visiting policy. It was observed that they were welcomed into the home and the visitors’ book indicated a steady stream of people came each day. Briarlea DS0000045857.V335748.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. People have the information and confidence they need to raise their concerns and believe they will receive an appropriate response. The staff have been well recruited and trained so that the risks to resident are well managed. EVIDENCE: The Commission for Social care Inspection had not received any concerns, complaints or allegations regarding the home since the last inspection. The pre-inspection questionnaire stated that the home had received three complaints. The records in the home indicated that these had concerned the smell in a bedroom following a flood, the condition of a bedroom’s décor and carpet, and a lost razor. They had all been investigated and appropriately responded to. The Statement of Purpose and Service Users’ Guide contained copies of the complaint procedure for the home and the questionnaire responses from residents and relatives indicated that they knew how to raise their concerns. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 15 During interviews with staff it was clear that they knew how to respond to any concerns that were brought to their attention. They were also aware of the response to make to any suspicions or knowledge of abuse of residents. The training matrix indicated that training had been provided. The staff confirmed that they had undergone an acceptable recruitment process and the documents confirmed that references had been taken up and checks had been made through the Criminal Records Bureau and of the Protection of Vulnerable Adults list. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 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 clean comfortable home that meets their tastes and needs. Action has been taken to ensure their safety while building work is in progress. The refurbishment of some areas of the main home needs attention as soon as possible to prevent a negative affect on the residents. Generally the risks of cross infection were well managed with the exception of the laundry. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 17 EVIDENCE: A partial tour of the home was undertaken. Building work on a large extension was in progress. Eight single rooms with ensuite facilities, a new laundry, storerooms, and a large sun lounge were under construction. One resident enjoyed watching the men at work. The manager confirmed that health and safety issues had been addressed. A fire door had been blocked off where the new building joined the old. However there were other convenient escape routes and the site manager had confirmed that the situation was acceptable. Bedrooms were clean, well furnished and personalised according to the wishes of the occupant. There were no offensive odours. One double bedroom was in the process of redecoration. In other areas the décor was ‘tired’ and in need of repair, redecoration and recarpeting. The manager said that the registered providers intended addressing this when the building work had been completed. The two communal lounges were comfortable and homely. There were good views at the front over the car park and main road and over the orchard at the back. The residents said that they enjoyed watching the comings and goings of people, rabbits and squirrels. The laundry was a small room that badly needed to be modernised and a sluice provided. It was observed that commode pots had been left to ‘soak’ with an unknown fluid in them. This was not conducive to infection control or health and safety. Liquid soap, disposable towels and personal protective equipment were readily available. It was observed that the fridges in the kitchen needed to be pulled out so that the floor could be cleaned. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 18 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 staff are available when residents needs are light or moderate but they are sometimes under pressure when people are ill. Training needs to be kept up to date to ensure the staff have the knowledge and skills to provide the care the residents need. EVIDENCE: The pre inspection questionnaire indicated that 19 care staff and 2 ancillary staff were employed in the home. Only two staff had left in the past twelve months and both had been replaced. Assessment of staff records confirmed that an acceptable recruitment procedure was used and checks had been made as required. Two staff came from Poland and one from Mauritius. The manager said that they had learned English quickly and two of them were taking English classes. Communication was not a problem. There was only one man on the staff team and the age range of the team extended from 28 years to 60 years. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 19 None of the staff had needs relating to religion or sexuality that needed support from the home. Some of the comments made by residents and relatives in the questionnaires were; ‘Sometimes could do with more staff on duty.’ ‘They are always too busy and short staffed’.’ Staff listen when they have enough time’. ‘Sometimes I have to mention my problem more than once’. The staff told the inspector that the staff levels were ‘generally fine’. ‘At that time it was great as people were more independent but when they were not it was more difficult’. The pre-inspection questionnaire indicated that nine staff had National Vocational Qualifications (NVQ) or were on courses. Fifteen people had first aid certificates. Relevant staff had received medication training but the training matrix demonstrated that several staff needed training or training updates in mandatory subjects. However the manager stated that all mandatory training was up to date. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 20 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 home is well managed and there are systems in place to ensure residents receive the care they need in a safe environment. The quality assurance system needs to be implemented so that areas that can be developed and improved can be identified. EVIDENCE: The registered manager had been in post for some time. She was experienced and well trained. The staff liked and respected her. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 21 They said that she listened and supported them. The staff from Poland said that she had been very supportive and helpful as they settled into England. The pre-inspection questionnaire stated that the registered providers visited the home twice a week and the responsible individual visited to assess the management of the home every twenty-eight days. Relatives said that the manager was approachable and responsive to any concerns that they had. She was proactive in the welfare of their relatives. It was observed that residents found her easy to approach and talk to. The home had the Mulberry Quality Assurance System. Although it was not yet in use the manager had taken a copy of the CSCI Annual Quality Assurance Assessment document off the Internet and was considering how to successfully use the two documents to support and inform each other. Questionnaires were distributed annually to residents, relatives, and visiting professionals and spares were always available from reception. Responses were analysed and the service improved where ever possible. The home had a policy of non-involvement in residents’ personal monies. Invoices were raised for any expenditure on such items as hairdressing and chiropody. The health and safety file containing risk assessments for the home was seen to be up-to-date. The Fire Risk Assessment had been carried out and the manager was working on the identified actions that needed attention. Fire safety checks, training and drills were all up-to-date and well recorded. Other checks were also carried out regularly for example on water, small electrical items and wheelchairs. The pre-inspection questionnaire indicated that policies and procedures were available and had been reviewed as necessary. Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 22 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 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP7 Good Practice Recommendations Initially assessments should include all topics to provide a base line for health and care needs. Residents, or with their consent their relatives, should be involved in the discussion and agreement of their care plans so that they are aware of how their needs will be met. The wishes of residents, or with their consent their relatives, should be sought regarding their end of life care and death so that they can receive the care they want. While waiting for the completion of the building work care must be taken that the current environment does not deteriorate and adversely affect the residents. 3 OP11 4 OP19 Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 24 5 OP26 Staff need to be constantly alert to the need to control risks relating to infection and the use of chemicals so that people do not come to harm. Staffing levels should be continuously reviewed to ensure changing needs of residents are met and the residents do not feel that staff are rushed and have little time to spend with them on other than practical tasks. Staff must receive the training they need to enable them to carry out their duties efficiently and effectively. 6 OP27 7 OP30 Briarlea DS0000045857.V335748.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Good information was available in the kitchen Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Briarlea DS0000045857.V335748.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!