Inspection on 13/12/06 for Briercliffe Lodge

This inspection was carried out on 13th December 2006.

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

Briercliffe Lodge 27/08/09

Briercliffe Lodge 23/08/07

Briercliffe Lodge 07/02/06

Briercliffe Lodge 03/10/05

Briercliffe Lodge 15/03/05

Briercliffe Lodge 24/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Briercliffe Lodge Rainhall Crescent Barnoldswick Lancashire BB18 6BS Lead Inspector Mrs Julie Playfer Key Unannounced Inspection 09:30 13th December 2006 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 Briercliffe Lodge DS0000009479.V315013.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. Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Briercliffe Lodge Address Rainhall Crescent Barnoldswick Lancashire BB18 6BS 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) 01282 816638 01282 816638 briercliffelodge@aol.com Mrs Gillian Eyton-Jones Mrs Rebecca Eyton-Jones Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing levels as specified in notice of proposal to grant registration subject to conditions dated 25 October 2002 7th February 2006 Date of last inspection Brief Description of the Service: Briercliffe Lodge is registered with the Commission for Social Care Inspection to provide accommodation and personal care for seventeen older people. The home is owned and managed by Mrs Gillian Eyton-Jones and Mrs Rebecca Eyton-Jones with the support of a deputy manager and senior staff. Staff are on duty and available twenty-four hours a day. The home is a detached property set in its own grounds, with outdoor seating areas and car parking facilities. It is located in a residential area on the outskirts of Barnoldswick. Accommodation is provided on two floors in thirteen single and two double bedrooms. The upper floor bedrooms can be reached by using a stair lift. There are comfortable lounges, dining rooms and conservatory. There are two assisted bathrooms and seven bedrooms with en suite facilities. At the time of the inspection, the scale of fees ranged from £320 - £370. Additional charges were made for hairdressing (£6.00 and £22 for a perm), private chiropody, holidays, personal magazines and newspapers and individual activities. Information was made available to prospective residents by means of a statement of purpose and service users guide. The guide was usually given to prospective residents and/or their relatives on viewing the home or at the point of assessment. Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Briercliffe Lodge on 9th January 2007. At the time of the inspection there were 17 residents accommodated in the home. The inspection comprised of spending time with the residents, looking round the home, looking at residents’ care records and other documents and discussion with the staff and the registered persons. As part of the inspection process the inspector used “case tracking” as a means of gathering information. This process allows to the inspector to focus on a small group of people living at the home. Prior to the inspection the registered manager completed a questionnaire, which provided useful information and evidence for the inspection. Comment cards were sent to the home for residents and their relatives. 4 cards were returned from relatives/visitors to the home and 6 cards were received from the residents. What the service does well: The admission procedures involved an assessment of peoples’ needs. This enabled the registered persons and prospective residents to determine whether or not the home could meet their needs. Each resident had a plan of care. This document provided details about the residents’ personal and healthcare needs, which meant the staff had clear guidance on how best to meet the residents needs. Residents spoken to felt they received a good standard of care and the staff respected their rights to privacy and dignity. The residents described the staff as “very nice and caring” and one person said “they’re really good to us here”. Varied, nutritious and well-presented meals were served. All the residents spoken to said the meals were “very good” and confirmed there was always plenty to eat, with a choice each mealtime. Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. All the relatives and visitors who completed a comment card expressed satisfaction with the overall care provided. Residents were provided with clean and nicely decorated bedrooms that were well-maintained. All residents spoken to said they felt the home was always kept clean and was very comfortable. Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 6 A high percentage of staff had achieved NVQ level 2 or above, this meant the staff had received the necessary training to enable them to carry out their caring role effectively. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Briercliffe Lodge DS0000009479.V315013.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 Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The admission procedure was well managed. The residents had their needs properly assessed and they were provided with appropriate written information to enable them to make an informed choice about where to live. EVIDENCE: Written information was available for residents in the form of a statement of purpose and service users guide. The guide was presented in a suitable format and was readily accessible in all bedrooms. Both documents provided useful information about the services and facilities provided in the home. All residents were issued with a statement of terms and conditions of residence or contract. It was noted the contract had been signed by the residents and/or their representative and included information about the current level and payment of fees. Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 9 The ‘case tracking’ process demonstrated that the residents had their needs assessed prior to admission to the home by a social worker and/or the registered persons. The registered persons had also informed the residents in writing that having regard to the assessment the home was suitable for meeting their needs. Prospective residents were actively encouraged to spend some time in the home prior to making the decision to move in. Both residents new to the home had visited the home with their family prior to admission. Briercliffe Lodge DS0000009479.V315013.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The health and personal care received by the residents was based on their individual needs. However, the care planning process could be improved with more consultation with the residents. EVIDENCE: From the case files seen, it was evident each resident had a plan of care, based on an assessment of needs. The plans were supported by records of personal care, which provided information on changing needs and any recurring difficulties. All records seen were detailed and the residents’ needs had been described in respectful terms. However, whilst five of the six residents who completed a comment card indicated they “always” received the care and support they needed, not all changing needs had been recorded on the care plan. None of the residents spoken to could recall discussing their care needs with a member of staff and there was no documentary to indicate the residents had been involved in the care planning process. Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 11 Risk assessments had been incorporated into the care plan documentation, which included risk management strategies to manage, reduce or eliminate an identified hazard. Healthcare needs were appropriately assessed and were included in the care plan. There was evidence to indicate the residents had access to NHS services and advice from specialist services had been sought as necessary, for instance the District Nursing Team. A separate chart was maintained to monitor the residents’ weight. The residents spoken to felt the staff respected their right to privacy and all made complimentary remarks about the staff, for instance one resident said the staff were “really kind and they look after us well”. The staff were observed to interact with the residents in a positive manner and they referred to the residents in their preferred term of address. The home operated a monitored dosage system for the administration of medication, which was dispensed into blister packs. Policies and procedures were available to cover all aspects of managing medication in the home. Appropriate records were in place to record the receipt, administration and disposal of medication. Systems were in place for the management of controlled drugs. Protocols had been written for the administration of medication prescribed “as necessary”, however, some of the protocols were not up to date. All the staff designated to administer medication had received accredited training. Briercliffe Lodge DS0000009479.V315013.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were able to exercise choice and control over their lives and maintained good contact with their family and friends. The residents were provided with a nutritious varied diet according to their assessed requirement and choice. EVIDENCE: The residents’ preferences in respect of social activities had been recorded as part of the assessment. The residents were encouraged to pursue a range of activities. Activities included music and movement, quizzes, baking, memory games and hand and foot massages. The residents also visited the local shops and some town square activities. The residents spoken to were satisfied with the type and frequency of the activities provided. All the residents particularly enjoyed the music and movement, one resident said “I really like dancing and singing” and another person said, “I always join in with the exercises”. The routines in the home were well established and residents had a choice in the times they went to bed and got up in the morning. One resident said “I like to go to bed early and get up early”. Breakfast was served throughout the morning to suit the wishes of the residents. The staff were observed to seek Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 13 the views of residents throughout the inspection and residents said they felt comfortable to comment on life in the home. There were no restrictions placed on visiting and residents were able to entertain their guests in the privacy of their bedrooms. All the relatives and visitors who returned comment cards said that they felt welcome in the home and all were satisfied with the level of care provided. Residents spoken to described the meals as “very good” and “lovely”. They also said there was always plenty to eat and the food was a good quality. There was a choice of food at every mealtime and residents were asked what option they preferred. The meal looked appetising and was well presented. Drinks and snacks were served at set times throughout the day and other times on request. Residents were observed asking for drinks during the inspection and were promptly served by the staff. The menu was displayed in the hallway and residents were aware of the forthcoming meal. Briercliffe Lodge DS0000009479.V315013.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Systems were in place to ensure any concerns of residents would be acted upon. Policies and procedures were in place to respond effectively to any allegations or suspicions of abuse. EVIDENCE: The complaints procedure was incorporated in the service users guide and displayed in porch. The procedure contained the necessary information should a resident wish to raise a concern with the home or direct to the Commission. The home had not received any complaints since the last inspection. The residents were aware of the procedure and knew who to speak to if they had a concern. There was a copy of “No Secrets in Lancashire” (The Joint Strategy for the Protection of Vulnerable Adults) and an adult protection procedure specific to the home. The procedure set out the appropriate response in the event of any allegation, suspicion or evidence of abuse. The staff had access to a whistle blowing procedure and had received training on safeguarding vulnerable people. Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 15 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, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents were provided with a clean, comfortable and well- maintained environment. EVIDENCE: Briercliffe Lodge is a mature detached property set in its own grounds. The residents had access to the garden areas and there was a patio for use in fine weather. Accommodation is provided in thirteen single bedrooms and two double bedrooms. Seven of the single bedrooms have an ensuite facility. Communal space is provided in two lounges, one of which is also a dining room and a conservatory. On a tour of the premises it was evident the residents had personalised their bedrooms with their own belongings and decoration was good throughout. The residents said their rooms were comfortable and warm. One person also said “my room is very nice and very clean”. Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 16 The bedroom doors had been fitted with appropriate locks and keys had been distributed to the residents. Arrangements were in place for routine maintenance. Further to this, scaffolding was being erected on the day of inspection to replace some tiles on the roof. Radiators had been fitted with guards. To prevent scalding all water outlets had been fitted with a preset valve to guarantee water was delivered close to 43 degrees Celsius. A call system with an accessible alarm was placed in every room. Since the last inspection, seven bedrooms had been redecorated in line with the choices and preferences of the residents occupying the rooms and the toilet had been removed from the hallway. The home was clean and hygienic in all areas seen, during the inspection. Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 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, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements were in place to ensure staff were employed in suitable numbers and received appropriate training in line with the needs of the residents. EVIDENCE: The registered persons maintained a staff rota, which staff were on duty at any time on a particular day. All staff providing personal care were aged over 18 and all staff left in charge of the building were aged over 21. The number of staff on duty was sufficient for the number of residents living in the home. The files of two members of staff, who had commenced work in the home since the last inspection, were examined. Both staff had completed an application form and had attended the home for a face-to-face interview. Appropriate police checks had been sought and received prior to the staff commencing work in the home. However, it was noted that one applicant had not provided a full working history and only one written reference and a verbal reference had been received for this person prior to employment. Documentation seen during the inspection demonstrated that all new employees undertook an in house induction programme and competed a “Skills for Care” induction. The latter provided underpinning knowledge for NVQ level 2. At the time of inspection the equivalent of 79 of the care staff were trained to NVQ level 2 or above and a further member of staff was working Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 18 towards this qualification. Staff also attended both internal and external training courses and had at least three paid days training a year. Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 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): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The residents benefited from the ethos and management approach in the home, however, consultation could be improved by arranging more residents’ meetings. The arrangements in place for testing the electrical installations must be improved. EVIDENCE: Both the registered persons had achieved NVQ level 5 in Operational Management and were Registered General Nurses. The registered persons had managed the home since 1988. Relationships within the home were good and staff spoke about the residents with respect. The residents valued the help and support they received from the Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 20 staff, who they described as “very good” and “caring”. There was a programme in place for staff supervision and the topics discussed during supervision were recorded on a suitable format. The home achieved an Investor’s in People Award in November 2001 and this was reaccredited in April 2004. Satisfaction questionnaires had been distributed to the residents and their relatives in April 2006. The results had been collated and were available in the home for reference. The residents were consulted informally as part of daily practice in the home, however a residents’ meeting had not been arranged for some time. An annual development/operations plan had been developed in 2006, setting out the objectives for the forthcoming year. Appropriate arrangements were in place for handling money, which had been deposited with the home by or on behalf of a resident. A random check of monies was found to be correct. Records were also maintained in respect to the amount of fees charged and received. There was a set of health and safety procedures available, which included the safe storage of hazardous substances. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. The registered persons and the staff had also completed an infection control course. Information contained in the pre inspection questionnaire indicated that the gas and fire systems were serviced at regular intervals. However, it was apparent at the time of inspection that the electrical safety certificate had expired. The fire log demonstrated that staff had received instructions about the fire system and fire equipment was tested on a regular basis. Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X 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 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 2 Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 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 Timescale for action 15/02/07 2 OP9 13 (2) 3 OP29 19, Schedule 2 (as amended) 4 OP38 13 (4) The registered persons must ensure that any changing needs are entered onto the care plan, to ensure that staff have up to date guidance on how best to meet the needs of the residents. The residents must also be more involved with in the care planning process, so they are able to express their opinions on how their care is provided. The protocols written for the 15/02/07 administration of medication prescribed “as necessary”, must be reviewed to provide the staff with up to date information. To ensure the residents are fully 09/01/07 protected, two written references and a full working history, with a satisfactory written explanation of any gaps must be obtained from all new staff prior to working in the home. The electrical installations must 15/02/07 be tested and the electrical safety certificate renewed in order to fully protect the health and safety of the residents. Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 23 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 Good Practice Recommendations Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Briercliffe Lodge DS0000009479.V315013.R01.S.doc Version 5.2 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. 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!