Inspection on 11/10/06 for Brierfield House Care Centre

This inspection was carried out on 11th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Brierfield House Care Centre 15/07/09

Brierfield House Care Centre 20/08/08

Brierfield House Care Centre 19/03/08

Brierfield House Care Centre 13/08/07

Brierfield House Care Centre 27/04/06

Brierfield House Care Centre 24/11/05

Brierfield House Care Centre 12/10/04

Brierfield House Care Centre 06/04/04

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 Brierfield House Care Centre Hardy Avenue Brierfield Nelson Lancashire BB9 5RN Lead Inspector Mrs Pat White Unannounced Inspection 11th October 2006 09:30 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 Brierfield House Care Centre DS0000022499.V308350.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. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brierfield House Care Centre Address Hardy Avenue Brierfield Nelson Lancashire BB9 5RN 01282 619313 01282 698477 brierfield@ashbourne-houses.co.uk 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) Ashbourne Homes Limited Mrs Kathleen Leach Care Home 42 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (26), of places Physical disability (1) Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The service is registered to provide personal care for a maximum of 42 service users A maximum of 41 service users who fall into the category of OP (Older People) One named service user who falls into the category of PD. A variation application must be submitted to the CSCI to remove this category when this person no longer resides in the home. 27th April 2006 Date of last inspection Brief Description of the Service: Brierfield House is a residential care home registered to provide care and accommodation for 27 older people and 15 older people with dementia. The 27 older people occupy the ground floor and part of the first floor. They have the use of a lounge, a dining area and a conservatory on the ground floor. The residents with a diagnosis of dementia reside in a self -contained unit occupying the rest of the first floor. The dementia unit has its own dining area, lounge and separate staircase access to the outside grounds, part of which was adapted for exclusive use of the residents in the unit. A passenger lift provided access between the two floors. The home is purpose built, in its own grounds, on the outskirts of Brierfield. All bedrooms are single and en suite and measured 11 sq m. A part time activities organiser is employed in the home and there was a programme of varied activities. There were 6 WCs, 3 bathrooms and 2 shower facilities. Fees were given as £366 - £422 per week and cover all aspects of care, accommodation, food and laundry. Hairdressing, chiropody, papers, magazines and some trips are not included in these fees. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second unannounced “key” inspection of the home in 2006. The first inspection took place in April 2006, and gave cause for concern in a number of important areas in the home, such as staffing levels and medication. This resulted in an “Improvement Plan” being implemented in the home. The purpose of this second inspection was to monitor the improvement plan, check the progress made on all the matters that needed improving from the previous inspection, check other important areas of life in the home that should be checked against the National Minimum Standards for Older People and to again determine an overall assessment on the quality of the services provided in the home. The inspection included: talking to residents, touring the premises, observation of life in the home, looking at residents’ care records and other documents, discussion with members of staff and discussion with the general manager, Mrs Kathleen Leach. In addition survey questionnaires from the Commission were completed on behalf of 19 residents, and two relatives also completed comment cards. A district nurse was also spoken with. What the service does well: The way people’s needs were assessed before they went to live in the home made sure that these needs were understood by the staff and a decision could be made about whether or not the home could meet their needs and if a placement in the dementia unit would be suitable. The written records of resident’s needs were well written, and covered all the important matters regarding health and personal care needs. The written plans for residents’ care were detailed and well written, and contained useful information regarding the residents’ health, personal and social care needs. These written plans were regularly reviewed and updated. The residents who were spoken with, and those who completed the survey questionnaire, stated that they felt well looked after and that they received the care they needed from the staff. One resident said that she was “well looked after”. Another resident said, jokingly and intending to be complimentary, “Staff are very attentive, I sometimes get too much attention!” Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 6 The home employed an “activities organiser”, and there was a varied programme of activities, including outings and celebrations. The home provided pleasant, bright and modern accommodation for the residents. It was attractively furnished and decorated. All the bed - rooms are single and en suite. The way the home recruited care staff to work in the home was thorough, and according to the Regulations, and helped to protect residents from unsuitable staff. There was a good programme of staff training, and staff did training according to their own needs and the needs of the residents. The home regularly carried out its own checks to find out how good the care and services provided in the home are. Residents’ money was well managed to make sure their finances were safeguarded. Some aspects of the residents’ and staff health and safety were well looked after. The building, the services and the facilities were well maintained. What has improved since the last inspection? A lot of areas of care and management in the home had improved since the previous inspection. The information collected about the residents’ needs before admission to the home was more detailed and wide ranging and helped staff know how to meet these needs. More details about residents’ health and care needs was being written down, such as how to prevent falls, improve nutrition and help residents with mental health problems. A communication book was being used to help improve communication with the district nurses. Following frequent checks by the home’s senior managers, the way the home managed resident’s medication had improved; systems were in place to check that medicines had been managed safely. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 7 The activities organiser was spending time with individuals trying to find out what their interests and abilities were, including those who are immobile and those who can’t hear and see. The home was cleaner and fresher in most areas. The staffing numbers in the home had been reviewed, and shifts reorganised so that there was another carer was on duty in the early evening. This made it more likely that the needs of the residents could be met. 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. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 & 5. Standard 6 was not applicable. Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. The home’s admission procedures, including pre admission assessments and prior visits by prospective residents and relatives to the home, helped to determine whether or not the home could meet people’s needs. EVIDENCE: The records viewed of some older people and some older people with dementia showed that the general manager or unit manager had visited them before admission to find out if Brierfield House could give the kind of care needed. Copies of social workers’ assessments had also been obtained for those residents who were assisted with fees. One resident confirmed that he and his wife had made an informed choice about him going to live permanently at Brierfield House. Those residents who were admitted to the dementia unit had an appropriate diagnosis of dementia and mental health assessments. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 10 Most residents spoken with stated that they were well looked after, including a newly admitted resident who stated that he was very well looked after. One resident under 65 years of age stated that he was “champion” and that he did not feel that living with older people was wrong for him. All staff in the dementia unit had undergone dementia training and the general manager stated that all staff throughout the home were to undertake such training. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 11 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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The care plans contained a good level of detail in most matters and showed what action staff needed to take. Residents’ health care needs were met and fully recorded. Medication management and procedures were much improved although staff had not consistently followed safe procedures and this could put residents at risk. Some aspects of the respect of residents privacy and dignity could be improved. EVIDENCE: The care plans of four residents were viewed, and these were well completed with a good level of detail. There was evidence of regular reviews to which relatives were invited. However on some care plans some “social history” sections had not yet been completed, including spiritual matters and hobbies. Records of appointments and visiting professionals and discussions showed that residents general health care was monitored and addressed. There was evidence of ongoing contact for residents in the dementia unit with the Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 12 psychiatric services for older people. Detailed risk assessments were undertaken on vulnerability to pressure areas, nutrition, moving and handling, falls and continence. These risk areas had detailed care plans which stated how they were to be managed, and these had improved since the previous inspection. Since the previous inspection the home had set up a “Communication book” for the District Nurses, to improve communication between them, especially with respect to falls. However it was still not clear that all falls were being reported appropriately to the district nursing team. The district nurse spoken with stated that she felt that overall communication had improved between themselves and the home, but that not all staff used the book properly. In spite of previous requirements, one resident was observed being pushed in a wheelchair without footrests being used, and therefore placed the resident at risk of injury. Residents on the dementia unit had not been provided with call leads to summon assistance from staff. Staff should provide information in the care plan to support why this decision had been made. A good standard of care was reflected in the residents’ survey where 9 stated that they “always” received the care and support they needed, 6 said they “usually” did and 4 said “sometimes”. Seven said staff were “always” available when they need them, 6 said “usually” and 5 said “sometimes”. Ten residents stated they “always” received the medical care that they needed, 7 said “usually” and 2 said “sometimes”. All those residents spoken with stated that they were well cared for and that staff were attentive. All aspects of medication management were looked at. Staff were trained and competent, the records were clear and accurate and the home had good systems in place to check that medicines had been managed safely. However the inspector found some tablets on the dining room table where a resident was sitting. The tablets were not hers; another resident had not taken them, and staff had not followed the correct procedure in this instance. This potentially put residents at risk from taking other people’s medication. Most residents spoken with stated that they were satisfied with the personal care given and the way it was carried out. However there was evidence that some aspects of residents’ privacy and dignity could be improved. One resident was concerned that her unique and sensitive care needs, which partly concerned her personal appearance and therefore her dignity, were not fully understood by staff or met. This was discussed with the general manager who agreed to review this situation. Also an incident was observed at the time of the inspection which did not uphold a residents’ dignity. This was also discussed with the general manager who agreed to address this. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 13 Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 14 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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. There were varied leisure activities which appeared to suit the needs and preferences of the majority of residents. Residents had sufficient choices in their everyday lives and were enabled to maintain contact with their relatives and the community. The food served usually met the needs and the preferences of the residents. EVIDENCE: There were a wide variety of activities to suit the interests and capabilities of most of the residents. This was generally the responsibility of the part time activities organiser, and a new activities organiser had spent time looking at the needs of individuals and on “one to one” activities. Records, and the homes notice board showed a wide range of activities such as crafts, celebrations, quizzes, trips out, massages and reminising. There were opportunities for contact in the local community through trips out and fund raising events held in the home. At the time of the inspection an Autumn Fayre was being organised. Of the 19 residents who completed the questionnaire survey 6 said that suitable activities were “always” provided, 9 said “usually” and 3 “sometimes”. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 15 Hobbies, interests and spiritual matters were recorded on some care plans, but not always on those of the most recently admitted residents. Two relatives who completed comment cards confirmed that visitors were made welcome at any reasonable time, according to the home’s visiting policy. Relatives were encouraged to attend activities and events, and residents’ reviews. Those residents spoken with who could express views indicated there was sufficient choice in such matters as rising and retiring times and whether or not they could stay in their rooms. Most residents had brought small items of furniture to personalise their rooms. One resident had the assistance of an independent advocate. Some residents managed their own finances and were assisted by staff to do this. There was some evidence that the food served had improved since the catering had been brought back “in house” from an outside catering company. The menus supplied indicated that the food served was nutritious and varied. There was a choice of two main (cooked) meals and desserts for the evening meal. Assistance was given to those who needed it and food was served in a suitable form for those with eating difficulties. Drinks and biscuits were served at times throughout the day. In the residents’ survey 7 said they “always” liked the food, 8 “usually” and 2 “sometimes”. One said they were “impressed with the choice of meals”. Most of the residents spoken with stated the food was good, one said it sometimes was. One resident said the food was “excellent”. One resident stated that the food had improved since he had been on respite care. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. The complaints procedure was accessible to residents and visitors and residents stated that they knew who to speak to if they had any concerns. There were satisfactory policies and procedures to protect the residents from abuse and residents felt safe living in the home. EVIDENCE: The home had an adequate complaints procedure. Information supplied prior to the inspection (The Pre Inpection Questionnaire), and the home’s records showed that 6 complaints had been made to the home over the last year. This indicates that the complaints procedure was accessible to a number of people. No complaints had been made to the CSCI since the previous inspection and only one directly to the home. This had been addressed through the company complaints procedure. There had been a recent reduction in the number of complaints made to the home and this is felt to be due to the fact that relatives are now invited to 6 monthly reviews, and are able to air views and grumbles that can be resolved straight away. The resident questionnaires showed that 9 residents “always” knew who to speak to if they weren’t happy, 4 “usually” and 4 “sometimes”. Nine said they “always” knew how to make a complaint, 6 said they “usually” did and 2 said “sometimes”. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 17 There were policies and procedures to protect the residents from abuse and these had been found to be suitable at previous inspections. There had been no allegations or suspicions of abuse in recent times. Staff had the opportunity to attend in house training on the protection of vulnerable adults. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 18 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, 22, 23, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. The home was well maintained and furnished and provided pleasant, comfortable accommodation. The residents’ rooms were comfortable and personalised and suited their needs. The home was clean in all areas viewed and fresh in most areas. EVIDENCE: Brierfield House is a purpose built care home. The premises were well maintained, light and airy, comfortable, pleasantly decorated and furnished, and complied with fire regulations. A handy man was employed in the home. Maintenance and refurbishments were carried out when required and according to a programme of maintenance. The rooms viewed were well furnished and bedrooms were personalised. Some bed room carpets had been replaced with easy to clean floors to eliminate unpleasant odours. Some parts of the home had been recently re-decorated. The environment in the demntia unit had Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 19 been improved in accordance with the needs of people with dementia, for example sensory plaques and pictures to help people find their way around. Residents on the dementia unit had not been provided with call leads to summon assistance from staff; staff should provide information in the care plan to support why this decision had been made. Standard 25 was not fully assessed but it was noticed that some hot water pipes were not lagged and residents could potentially be at risk. There was a housekeeper in the home responsible for the laundry and the standards of cleanliness. The standards of cleanliness had improved since the previous inspection and all parts of the home viewed were clean including the bed linen. Generally all areas of the home were fresh smelling and the home was taking action to eliminate any odours. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. There were sufficient numbers of staff on duty to meet the needs of the residents, according to their dependency levels and expectations. There were good staff training opportunities, which ensured that the staff team had the necessary background and skills to understand most of the needs of the residents. There were good staff recruitment procedures that helped to protect residents’ from unsuitable staff. EVIDENCE: Since the previous inspection a review of staffing levels had taken place. Staffing shifts had been re organised and there was 1 additional hour of care each day for the older persons (OP) residents. This had improved the delivery of care in the evening from 5.00pm till 8.00pm. There were only 19 (OP) residents and staff on duty on the day of the inspection felt they could easily meet the needs of that number of residents. Rotas showed that this arrangement had been in place for a few weeks, and residents and staff spoken with confirmed that residents’ needs were better met than at the last inspection. In the residents’ questionnaires, 9 stated that they “always” received the care and support they needed, 6 said they “usually” did and 4 said “sometimes”. Seven residents said staff are “always” available when they needed them, 6 said “usually and 5 said “sometimes”. However one resident stated that she felt staff did not have as much time to spend with her as she would like, and the two relatives who completed comment cards stated that Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 21 they did not feel there was always enough staff on duty. The general manager stated that staffing levels would be kept under review as the number of residents increase. The staffing levels in the dementia unit remained the same and appeared to meet the needs of these residents. The pre inspection questionnaire stated that 25 out of 37 care staff had gained at least NVQ level 2, that is 78 . Therefore the standard of 50 of care staff being trained to at least NVQ level 2 had been exceeded. The staff recruitment procedures were thorough and in accordance with the Regulations. Staff had not commenced work until the necessary police checks were complete and until written references had been obtained. All the other necessary documentation according to the Regulations had been obtained. However on the application form of one member of staff whose records were viewed, the dates of previous employment were not clear, and the second reference was not from a previous employer. Staff had opportunities to attend relevant training courses, most of which were delivered by in house company trainers. The Induction Training undertaken by new members of staff was in accordance with Government guidance. All staff undertook mandatory training which consisted of moving and handling, fire safety, first aid and food hygiene. Adult abuse training was also undertaken by all staff. Staff working in the dementia unit completed a 3 day training course on dementia. Other staff also had the opportunity to attend this course. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 22 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, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. The home was managed by an experienced and qualified manager who was well supported by an operations manager. Quality assurance policies and procedures were implemented which took into account the views of residents and relatives. Residents money was managed safely and efficiently and the health and safety of both residents and staff were promoted. However the home was not notifying the Commission of all incidents affecting the health and welfare of the residents. EVIDENCE: The registered manager of the home (the general manager) is a registered general nurse with many years nursing experience and about 12 years experience as manager of Brierfield House. She had also completed the Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 23 Registered Managers Award and NVQ level 4 in Care. There were clear lines of accountability within the home and the organisation, with the general manager being responsible for 2 unit managers, the teams of care staff and the ancillary staff. She in turn was responsible to a senior general manager and an operations manager. The senior managers had carried out monthly visits to the home under Regulation 26. They had made other frequent visits to the home to ensure that the Improvement Plan had been implemented and that many of the previous requirements and recommendations had been met. Brierfield House carried out numerous quality monitoring exercises according to company policy. These involved residents’ surveys and monthly internal “audits” on different aspects of the service. A residents’ survey had been conducted in April of this year. Residents meetings were held to which relatives were invited. Financial records were looked at and showed that finances were managed safely and accurately. Two residents managed their own finances with the assistance of staff. Appropriate records were kept of the fees charged, Social Services service agreements and fees paid. Also appropriate records of residents’ spending money were kept, including money kept in the office safe, money given to residents and that spent on their behalf. One residents finances were checked and the amount of money in the safe matched the balance in the records. The health and safety of the residents and staff was promoted by the home’s policies and procedures. Records and staff spoken with confirmed that there was a continuous programme of moving and handling training, fire training and first aid training. All seniors were competent in first aid so that there was a competent person on every shift. Some had completed an infection control course. According to information supplied to the CSCI, and discussions with the manager, the gas installations, the central heating system, electrical wiring, portable electrical appliances, equipment including the lift and the water supply, all had current certificates of testing. A number of records were checked and it was noted that the electrical wiring had been tested in Jan 2006 but there was no certificate in the home. The general manager will locate this and forward to the Commission. Fire precautions were satisfactory - the equipment had been checked within the last 12 months, there had been a recent fire drill and the fire alarm was tested weekly. There was a current fire risk assessment and general risk assessments. Window restrictors are to be replaced to a width of 100mm. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 24 Accidents were recorded appropriately and these were audited monthly. However not all notifiable incidents under the Care Homes Reulations, including admissions to Accident and Emergency, were reported to the CSCI. Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 25 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 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 3 3 2 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP8 Regulation 13(4)(b) (c) Requirement Staff must use foot - rests on wheelchairs unless there is a written risk assessment to support this is against the residents’ best interests. (Previous timescales of 28/04/06 & 12/07/06 not met) The registered person must ensure that correct notifications of falls are made to the District Nursing team at all times. Staff must adhere to medication policies and procedures with particular reference to administration procedures. (Previous timescale of 12/07/06 not met) The registered manager must ensure that the privacy and dignity of all residents are upheld, and that the needs of one particular resident identified are reviewed and clearly understood by all staff. The registered person must ensure that residents are DS0000022499.V308350.R01.S.doc Timescale for action 03/11/06 2. OP8 13(4)(b) (c) 03/11/06 3. OP9 13 03/11/06 4. OP10 12(4)(a) 30/11/06 5. OP25 13(4)(a) 30/11/06 Brierfield House Care Centre Version 5.2 Page 27 6. OP38 13 protected from the hazards of hot surfaces. The home must ensure the electrical installation certificate is up to date and available for inspection. A copy to be forwarded to the Commission. 03/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The registered person should ensure that the “social history” part of the care plan, including hobbies and spiritual interests, are completed on all care plans and as soon as possible after becoming resident. Risk assessments should support non-provision of call leads. It is recommended that both references are obtained from previous employers and that the registered person ensures that application forms are completed properly. 2. 3. OP22 OP29 Brierfield House Care Centre DS0000022499.V308350.R01.S.doc Version 5.2 Page 28 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. 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