Inspection on 20/05/05 for Brigshaw House

This inspection was carried out on 20th May 2005.

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

Brigshaw House 17/11/08

Brigshaw House 27/05/08

Brigshaw House 24/07/07

Brigshaw House 21/11/06

Brigshaw House 04/10/05

Brigshaw House 05/10/04

Brigshaw House 18/05/04

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

CARE HOMES FOR OLDER PEOPLE Brigshaw House 2 Brigshaw Lane Allerton Bywater Castleford WF10 2HN Lead Inspector Stevie Allerton UNannounced 20th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Brigshaw House Address 2 Brigshaw Lane Allerton Bywater Castleford WF10 2HN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2868421 0113 2868421 Cymar Care Homes Ltd Mrs Pauline Barker Care home Only 21 Category(ies) of Old Age (21) Dementia (21) registration, with number of places Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5th October 2004 Brief Description of the Service: Brigshaw House provides a service for up to twenty one older people, some of who may have dementia, but who do not require nursing care. The home is managed by Mrs. Pauline Barker on behalf of the owners, Cymar Care Homes Ltd. The home is situated in Allerton Bywater, a former mining village midway between Leeds and Castleford and is close to local amenities and public transport. The building comprises an older house with the addition of purpose built accommodation. It is well maintained. Seventeen single and two double bedrooms are provided, together with good dining and sitting facilities. The general ambiance is domestic in character. The overall impression is that the accommodation is comfortable and well equipped. Outside there is good car parking space and at the back an extensive and well kept garden which is quiet and private. Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place without prior announcement and was carried out over a four-hour period during the afternoon. It was the first of two inspections planned to take place during the year beginning 1st April 2005. The Manager was on duty and assisted throughout the visit. There were a lot of visitors to the home during the afternoon, service users’ families, relatives of someone hoping to move in, and a representative of Cymar Care Homes, all of which were spoken to. Service users were spoken to singly, or in a small group in one of the lounges. Some said that they thought that unannounced inspections were a good thing, but were confident that an inspector could drop in at any time to this home and find everything “up to standard”. Some records and policies were also looked at during this visit. What the service does well: What has improved since the last inspection? Record keeping has continued to improve and the staff now have access to more information about medication which is prescribed to the service users. The building continues to be well maintained, with some external repainting having been carried out since the last inspection. More staff are taking part in National Vocational Qualifications (NVQ). Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 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. Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 & 4 The home provides very good written information about the services and facilities it offers, which allows prospective service users and their relatives to make an informed choice about whether the home can meet their needs. Careful assessment and pre-admission discussions ensure that the home does not take people whose needs cannot be realistically met. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which is displayed in a prominent position outside the office door, readily available to everyone. On looking through the file, it was found to contain all of the elements required by the regulations, but was presented in an easily readable style. Some relatives of a prospective service user had come to look round (their second visit) and discuss arrangements with the Manager. They expressed confidence in what the home could offer and were very complimentary about the atmosphere and homely surroundings. Arrangements were made for the Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 Page 9 service user to come for lunch and spend a few hours at the home before she decided. These pre-admission visits are part of the assessment process and complement the written information supplied to the home from hospitals, social workers, etc. Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 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 standard(s) 7, 8 & 10 There is a co-ordinated approach to care planning and the staff deliver personal care in accordance with the agreed plans. Specific plans to help with communication difficulties were good, ensuring that dignity is maintained. EVIDENCE: Care plans for three service users were examined in depth, the findings verified by discussion with them or their families. Written plans are based on initial assessment and reviewed and adjusted to reflect any changes at regular intervals. There are appropriate risk assessments in place, together with relevant plans to minimise identified risks. Where a family member has Power of Attorney and is able to act on behalf of an individual, there was a copy of the legal document on file. Health care needs are addressed, reflected in written records and in discussion with service users, including referral to dentists and hearing aid clinics where required. Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 Page 11 The Manager showed awareness about issues of confidentiality, when discussing alternative ways of keeping daily records for each service user. Service users said that they felt well supported by the staff, that they felt respected and were happy with the levels of choice and privacy they had. Relatives also said they were happy with the way the service users were treated; this was also evident from “Thank You” letters received by the home. Staff had produced some laminated cards with stock phrases and questions on them, in order to communicate discreetly with a person who was temporarily without a hearing aid. Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 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 standard(s) 14 Service users have the opportunity to take part in a range of activities and pastimes which the staff arrange, or to pursue their own interests. Families and other visitors are seen as an important part of the social life of the home and their involvement is encouraged. EVIDENCE: One service user was spoken to as she was on her way out to take a “constitutional” to the end of the road. Staff just ask that she lets them know when she is going out. Other service users gave examples of how they were able to do things the way they preferred, from having their hair done twice a week, to which social activities they take part in. Visitors, who were looking round the home prior to a relative moving in, described seeing how the Manager dealt with providing a service user with a different choice of meal, without any fuss or difficulty; they felt this was indicative of service users being respected as individuals and still being able to make their own choices. Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 Page 13 Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 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 standard(s) 18 The home has proper procedures in place for the protection of vulnerable adults. In practice, these have proved effective and staff should be praised for identifying a problem and bringing it to the Manager’s attention. EVIDENCE: Since the last inspection, some staff reported an incident to the Manager under the “whistle-blowing” procedure, regarding a colleague’s poor practice. The written documents showed that this was taken seriously and dealt with accordingly. Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 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 standard(s) 19 & 26 The home is well-maintained, provides a pleasing environment inside and outside and is kept to a good standard of cleanliness. EVIDENCE: The exterior of the front of the building had recently been repainted; the representative from the company said that the rear of the building would be done next. The Manager keeps a maintenance book, in which she lists jobs to be done and priority areas for the decorating programme. Two domestic assistants are employed, who also keep a record book for weekly routine jobs and the less regular, larger tasks. The home stands in extensive gardens, which include a vegetable plot in which tomatoes, cucumbers and runner beans are growing. One of the service users said that she enjoys walking in the garden and is keenly monitoring progress with the tomatoes. Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 Staffing is appropriate in terms of numbers and skills, to meet the needs of current service users. The recruitment process protects service users and the staff have also shown willingness to use the available procedures to protect the people in their care. Information passed on between shifts makes sure that staff know what the current state of health and welfare is for each service user. EVIDENCE: The home is almost fully-staffed, with only one vacant post for a full-time care assistant. Care staff are supported by part-time domestic and catering staff. The recruitment process for the latest staff member to join the team showed that appropriate document checks were done, as well as taking up references and making Criminal Records Bureau checks. Information was also available to show the induction training provided and the programme of regular supervision to be set up. Seven care staff are now registered for National Vocational Qualifications at level 2, as well as both cooks on level 1. A training update was being arranged on COSHH Regulations for care and domestic staff. The inspector sat in on the staff handover between shifts at 4.00pm. Verbal information was passed on to the oncoming shift by the Senior Care, who had led the morning shift. Written notes had also been made in the daily records. Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 & 37 The home is managed well, in the best interests of service users. The Manager has good relationships with staff, service users and their relatives and is particularly good at making sure that relatives are kept fully informed about any changes. There are systems in place for monitoring standards of care, either formally or informally. Records, policies and written procedures are simple but effective in ensuring that service users are safeguarded. EVIDENCE: The Manager is very “hands-on” and works alongside staff; she is supported by a Deputy. It was noticeable that there was contact with every visitor who came into the home and that relatives appear to find her approachable. Service users also expressed a high regard for the Manager. A representative from the registered provider makes regular monthly visits to the home and reports to CSCI on various aspects of the care and facilities. Internal questionnaires are also in use; some were being given to relatives Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 Page 18 during the visit and the care plans showed that comments made by service users in their questionnaires had been incorporated where possible, for example, comments about meals or activities. All of the records seen during the course of this inspection appeared to be accurate and up-to-date; improvements which were needed as a result of the last inspection had been put into place. Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x 3 3 x x x 3 x Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement No requirements were made at this inspection. Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations No recommendations were made. Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Brigshaw House J52 J03 S1427 Brigshaw House V226620 190505 Stage 4.doc Version 1.30 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. 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. 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