Inspection on 08/02/06 for Bricklehampton Hall Nursing Home

This inspection was carried out on 8th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Bricklehampton Hall Nursing Home 16/05/07

Bricklehampton Hall Nursing Home 20/09/05

Bricklehampton Hall Nursing Home 02/03/05

Bricklehampton Hall Nursing Home 30/11/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Bricklehampton Hall Nursing Home Bricklehampton Nr Pershore Worcestershire WR10 3HQ Lead Inspector Chris Potter Unannounced Inspection 8th February 2006 10:00 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 Bricklehampton Hall Nursing Home DS0000004098.V284517.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. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bricklehampton Hall Nursing Home Address Bricklehampton Nr Pershore Worcestershire WR10 3HQ 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 710573 01386 710460 Classic Care Limited Mrs Carol Ann Harris Care Home 55 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (55), of places Physical disability (10), Physical disability over 65 years of age (55) Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: Bricklehampton Hall is situated in a rural setting near Pershore and Evesham. The hall is a Regency building, which stands within seven acres of gardens and grounds, with views over the Bredon Hills. Over recent years the buildings and grounds have been considerably upgraded to a very high standard, in a style, which is in keeping with the period of the building. The home currently provides nursing care for fifty-five residents in spacious rooms with modern nursing equipment and facilities. The home provides a choice of ensuite, single and double rooms. Residents are able to have a telephone line in their bedrooms. Meals are prepared in a kitchen, which has been upgraded to a high standard. Menus are varied and take into consideration individual choice. There is a call bell in all bedrooms, communal areas, toilets and bathrooms. Emergency call pendants are also available for residents who wish to walk out in the grounds unattended. Activities and social events are organised by the activities organiser. Visitors are welcome at any reasonable time. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out for part of the day on the 8th February 2006. The inspection totalled 5 hours and focused on the care of the residents. On the day of the inspection the home was accommodating 51 residents. A tour of the home was undertaken, residents care records were reviewed, health and safety records reviewed and some residents and relatives were spoken with to establish their views about the home. What the service does well: What has improved since the last inspection? The registered provider continues to ensure the home is maintained to a high standard. The home continues to amend and update policies and procedures to reflect changes in care practice and good practice guidance. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 Page 6 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. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 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 Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 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): 1,2,3,4 and 5 The home provides prospective residents and relatives with appropriate information and advice to assist them in making their choice about the home. The manager assesses all residents prior to admission to ensure the home can meet the assessed needs of the prospective resident. EVIDENCE: All prospective residents are assessed prior to being admitted to the home. The manager completes a care needs assessment to ensure the home is able to meet those needs. The pre-admission assessment then forms the basis of the residents’ care documentation. The Service Users Guide is updated and reviewed appropriately Copies are given to potential residents to assist them in making a choice about the home and its provision. Relatives stated they were pleased with the home and how well their relatives’ care needs were being met by the home. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 Page 9 Staff spoken to were noted to have a good understanding of the individual needs and preferences of the residents in their care. There was a relaxed atmosphere within the home and good interaction between staff and residents. Bricklehampton Hall Nursing Home DS0000004098.V284517.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): 7,8,9 and 10 The residents’ care documentation reflected the residents’ care needs. EVIDENCE: Since the last inspection, the home has further developed their residents’ care plans and appropriate risk assessments had been completed. Staff in the home have an awareness of the of the mental health needs of residents, and in practice, provide ongoing support to ensure emotional and social needs are met The care documentation evidenced that the home accessed specialist advice as and when required. A physiotherapist visits the home once a month. In addition, the community physiotherapist visits as required. There was evidence that staff were encouraging residents to be more involved in the care planning process. Appropriate management systems were in place for the administration, receipt disposal and storage of medication. It was recommended that the home develop a protocol for sedatives and analgesics prescribed on an “as required” basis for residents. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 Page 11 Staff were observed interacting well with the residents, and residents confirmed that they were treated with dignity and respect from all staff. Bricklehampton Hall Nursing Home DS0000004098.V284517.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): 12,13 and 15 Social activities are well planned and organised, and provide a daily variation for people living in the home. The meals provided offer a choice, and specialist diets are catered for. EVIDENCE: The home employs a member of staff responsible for social activities. She works full time and this includes alternative weekends. Activities are developed appropriate to the residents’ needs and abilities. A record is maintained of each individual’s activities, which they choose to participate in. Visitors are made welcome in the home; the visiting times are open to assist with other commitments. Several residents were enjoying visits from family and friends at the time of the inspection. Comments received from residents and relatives were complimentary about the quality of food. The home is currently in the process of reviewing their menus to provide a more varied choice for the residents. Meals are served in a pleasant dining room for those choosing to eat meals in there. Some residents chose to eat in their bedrooms. Residents were being assisted appropriately by the staff with their meals where required. The lunch being served looked appetising. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 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 and 18 Complaints are reviewed thoroughly and residents are confident that their concerns will be taken seriously. A vulnerable adults procedure has been developed to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The home maintains detailed complaints records. One complaint has been received by the CSCI since the last inspection. The home is in the process of investigating the complaint and will forward the outcome of their investigation to the CSCI when it is completed. The complaints procedure is available in the service users guide. The home maintains detailed records of any complaints received directly to them; the records were reviewed at the time of the visit. These show that the home follow their complaints procedure. The home also receives many compliments from relatives expressing gratitude to the staff for their wonderful care and affection. The home has a procedure for responding to any potential allegations of abuse. All staff receive training during their induction period. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 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): 19,20,21,22, and 26 The home is maintained to a high standard and provides a safe, warm, comfortable home for the residents EVIDENCE: Bricklehampton Hall is very well maintained and provides a comfortable and homely environment for residents to live in. The home is surrounded by extensive gardens, which are accessible to all residents including those who may be dependant on the use of a wheelchair or have limited mobility. Since the last inspection the home has further developed the garden area. The home benefits from having a variety of communal areas, which are all accessible to residents. Residents were observed moving between rooms as preferred. The home employs a maintenance operative to attend to day-to-day issues as they arise. The manager has a system whereby she walks around the home Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 Page 15 doing checks, when opportunity is taken to identify and address any issues arising from the “management walkabout”. Given the size of the home and dependency of the residents the home was clean and tidy, the management of odours was commended. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 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 and 30 Staffing levels are appropriate to the number of residents in the home. EVIDENCE: Staff rotas confirmed that the home provides the appropriate number of staff to ensure the residents’ needs are met. The home allocates two registered nurses and eight care staff for the day duty, and one registered nurse and four care staff on night duty. The manager and deputy manager have supernumerary days allocated. In addition to nursing and care staff, there are activities co-ordinators, catering, domestic, laundry and maintenance staff working in the home. The atmosphere in the home was pleasant and staff were observed undertaking their duties in an unhurried manner. Residents who were spoken to were most complimentary about the staff and felt that their were enough staff on duty. The home ensures all staff are up-to-date with mandatory training. Recently several staff have completed basic food hygiene training and first aid. The home also acts as a placement for student nurses from a local university. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 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): 31,32,33,34 and 38 The manager is competent to ensure the needs of the residents are met. All staff are appropriately supervised. All records and registers were available and up to date. EVIDENCE: The manager has settled well into the managerial role and is in the process of completing the NVQ level 4 in management. Staff confirmed that the manager was approachable and always available to discuss anything with them. Detailed quality assurance systems are in place this includes monthly accident analysis, an admissions follow up, catering surveys, and housekeeping surveys. Plans are in hand to commence a post-admission welcome form. The home has a policy whereby it does not look after the residents’ money Positive health and safety practices are promoted, fire tests and fire training were up-to-date at the time of the inspection. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 Page 18 The home reviews and updates its policies and procedures with changing legislation. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 4 4 4 X X X 4 STAFFING Standard No Score 27 4 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X X X 3 Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 Page 20 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. Refer to Standard OP9 Good Practice Recommendations 1. It is recommended that the home develop a protocol for residents prescribed for analgesics and sedatives as required. Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester 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 Bricklehampton Hall Nursing Home DS0000004098.V284517.R01.S.doc Version 5.1 Page 22 - 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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