Inspection on 24/07/07 for Brigshaw House

This inspection was carried out on 24th July 2007.

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

Brigshaw House 17/11/08

Brigshaw House 27/05/08

Brigshaw House 21/11/06

Brigshaw House 04/10/05

Brigshaw House 20/05/05

Brigshaw House 05/10/04

Brigshaw House 18/05/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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 West Yorkshire WF10 2HN Lead Inspector Ann Stoner Key Unannounced Inspection 6.00pm 24th & 25thJuly 2007 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 Brigshaw House DS0000001427.V347048.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. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brigshaw House Address 2 Brigshaw Lane Allerton Bywater Castleford West Yorkshire WF10 2HN 0113 2868421 F/P 0113 2868421 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) Cymar Care Homes Limited Mrs Pauline Barker Care Home 21 Category(ies) of Dementia (21), Old age, not falling within any registration, with number other category (21) of places Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2006 Brief Description of the Service: Brigshaw House provides a service for up to twenty one older people, some of whom may have dementia, but do not require nursing care. 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 of an older house with the addition of purpose built accommodation. There are seventeen single and two double bedrooms, good dining facilities and spacious sitting areas. There is car parking space at the front of the home and at the back there are extensive and well kept gardens, which are quiet and private. Copies of previous inspection reports are available in the front entrance of the home. On the 25th July 2007 the manager said that the fees ranged from £381.01 - £400.00 per week. More up to date information can be obtained from the home. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. More information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and was carried out by one inspector who was at the home from 6.00pm to 9.15pm on the 24th July and 6.35am to 4.00pm on the 25th July 2007. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people living there. Before the inspection evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the visit. An AQAA (Annual Quality Assurance Assessment) was completed by the home before the visit to provide additional information. Survey forms were given to people living at the home, and information from those returned is reflected in this report. During the visit a number of documents were looked at and all areas of the home used by the people living there were visited. A good proportion of time was spent talking with the people who live at the home and their relatives, as well as with the manager and staff. Feedback at the end of the visit was given to the manager. I would like to thank everyone who contributed to the inspection process and to the home for the hospitality throughout the two days. What the service does well: The home works hard to create a warm, relaxed and friendly environment. One person living at the home described it as being ‘home from home’. The staff team are aware of the importance of people keeping links with their family and friends, and relatives spoke of the support that they receive. One relative said that the manager was like ‘a big sister, always willing to offer help, support and advice’. Another said that all of the staff were ‘friendly’, which was confirmed by another person who went on to say, ‘staff can’t do enough for you’. A person living at the home said that everyone had been a source of support and comfort during a recent bereavement. Relatives said there are no offensive smells in the home, and confirmed that it is always clean and tidy. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 6 People thinking about moving in are invited to visit before making any decisions. This invitation is extended to their friends and family. One person said that the manager was ‘very informative’, and another said he visited unannounced and was made very welcome. What has improved since the last inspection? To make access easier for people with a disability there is a ramp at the entrance to the home. Communal rooms have been decorated and a new carpet has been fitted in one lounge. Individual signs, photographs and pictures have been fitted on some people’s bedroom doors to make it easier for them to find and recognise their room. An evening part time cook has been employed. This means that care staff should not have to prepare and clear away the teatime meal. More staff have completed an NVQ (National Vocational Qualification) award in Care, which means that 75 of the staff team now have this qualification. An external training provider now delivers training, such as moving and handling and first aid. Training for staff has been arranged on subjects including adult abuse, food hygiene and fire safety. The manager has devised a training plan that shows when staff have completed training. Nutritional and falls risk assessments are carried out to identify who may be at risk. The manager has made a start at updating care plans to make sure that staff have clear and precise information on how to provide care according to people’s needs. At the point of admission, people have a statement of terms and condition of the home. This makes sure that people are aware of the current fees and the rights and responsibilities of all concerned. Health & safety issues have been addressed, for example the home no longer has a supply of oxygen. Evidence of recruitment checks is kept in the home and is available for inspection. Infection control is well managed. There is liquid soap and disposable towels in all toilet areas. To prevent cross infection staff use water-soluble bags when laundering soiled linen. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 7 What they could do better: Although some work on developing care plans has taken place, much more work is required to make sure that everyone living at the home has a plan of care that shows their needs and the actions that staff need to take. This will make sure that people’s needs are met. Where nutritional and falls risk assessments show that a person is at risk, a care plan must be in place showing the action that must be followed to reduced the risk. Care plans must be in place for people at risk of developing pressure sores and those using bed safety rails. This action will reduce risk and prevent needs from being overlooked. There must be sufficient numbers of staff on duty at all times. This will make sure that people’s needs are met. All medication not being used must be returned to the pharmacist for disposal. The home must not transfer medication from one container to another. This will make sure that the risk of errors is reduced and correct procedures are followed. A full and varied activity programme must be developed that meets the needs of everyone living at the home. This will make sure that people have recreation and leisure activities that meet their interests, choices and abilities. All staff must have training on adult abuse. This will make sure that they recognise abuse and respond properly if they suspect abuse is happening. The manager must complete an NVQ (National Vocational Qualification) level 4 in Care, so that she meets the requirements of the National Minimum Standards for Care Homes for Older People. Bed safety rails must not be used until a full risk assessment has been carried out. When bed safety rails are in use the home must follow safe guidelines issued by the Medical Devices Agency. This will minimise any risk to the person using the bed safety rails. Doors must not be propped open with wedges. This will reduce the risk to people in the event of a fire. Written information for people living at the home should be revised so that the information is easier for them to understand. To promote people’s independence the home should consider using tureens and gravy boats on dining tables, and small teapots, milk jugs and sugar basins to create a more homely setting. Some recommendations were made relating to records kept in the home, such as staff rotas, staff application forms, financial records, accident records and quality surveys. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 8 A full list of the requirements and recommendations made as a result of this inspection can be found at the end of this report. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 9 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 Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 & 5. Standard 6 does not apply to this home. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Written information about the home is not in a style that is easy for everyone to read and understand. Poor assessment records create the risk of care needs being overlooked. EVIDENCE: The statement of purpose and service user guide, which gives people information about the home, is on display in the front entrance. These documents need updating to reflect the actual care provided, particularly relating dementia care and to make sure that the format is appropriate to the needs of people living there. For example, using a larger font size, colour, photographs and visual prompts making it easier to read. Discussion took place on how to make these documents more accessible to everyone. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 11 The assessment details of two people recently admitted to the home were sampled. One person had been living at the home for 7 days and although the manager and his family confirmed that a pre-admission assessment had been carried out, the only recorded information was a nutritional assessment and a falls risk assessment. A record was later produced which suggests that information is not recorded at the time that assessments are carried out. The relative of this person said that she and her husband visited the home to make sure it could meet her stepfather’s needs. They were delighted because it was in an area that her stepfather knew well and since his admission he has met up with friends he has known since childhood. She said that the manager was very informative and supportive throughout the introductory visit. Another relative, who said that he had visited unannounced, echoed this view. The assessment information for the second person was insufficient and did not reflect the person’s needs. Both people had a signed contract of the home’s terms and conditions. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, & 10. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People’s needs are met, but poor record keeping creates the risk of some needs being overlooked. Some medication practices create the potential for error and misuse of medication. EVIDENCE: Since the last inspection the manager has worked at improving care records but much more work is needed to bring them to a satisfactory standard. There were no care plans in place for one person who had been living at the home for 7 days. This person is frail, at serious nutritional risk and at risk of falling. His relative said that she was pleased with the way that the home was addressing his nutritional needs, but because there were no care plans in place staff do not have accurate information on how to provide consistent care to meet this person’s specific needs. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 13 Staff explained in detail about the care given to another person, but again much of this was not recorded in his care plan. For example his nutritional assessment showed that he was at high risk, and staff were seen encouraging nutritious snacks such as cheese and biscuits between main meals, but he did not have a dietary care plan. He was assessed as being at high risk of falling and had sustained two falls in the home, but he did not have a care plan for the prevention of falls. Staff were seen prompting him to use the toilet and said that he used continence products, but he did not have a continence care plan in place. One person had a detailed personal hygiene care plan but no plan for the use of bed safety rails. Another person had a pressure relieving mattress on her bed but no care plan for pressure area care. The home is registered for, and has a number of people with dementia. There are no care plans in place showing the type of dementia or how it affects the person’s life, their strengths, levels of functioning and instructions for staff on how to encourage and support the person to maintain their skills and strengths. Care records showed that doctors, district nurses, chiropodists and opticians visit people living at the home. During the inspection, a chiropodist and two doctors visited. Staff described how by observing and having a good knowledge of one person’s behaviour they were able to identify a deterioration that triggered a subsequent hospital admission. A member of staff was observed giving out evening and night medication; she followed correct procedures. People living at the home said that they always received their medication at the correct time. Medication Administration Records (MAR) were recorded properly and there was a clear photograph of each person against their record sheet. Some areas of concern relating to storage, administration and disposal of medication were noted. One person was prescribed 5mg and 4mg of Warfarin on alternate days. There was a box of 5mg Warfarin in the medication trolley, but the 1mg and 3mg dose, which had been dispensed by the pharmacist in a monitored dose system, had been secondary dispensed by staff into a bottle. The manager agreed that this was unsafe and said that she would rectify it immediately. Haloperiodol dispensed in April 2007 for a person who has since died had not been returned to the pharmacist for disposal. A number of Senna tablets in three different part used monitored dose systems dating from December 2006 were found in a drawer in the medical room. A box of part used Paracetamol tablets that had a person’s first name written across the front of the box, were also found in a drawer in the medical room, along with food supplements originally dispensed for a person who died in March 2007. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 14 Throughout the inspection staff respected the privacy and dignity of people, and through discussions with people living at the home it was clear that this is common practice. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 & 15. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People living at the home enjoy a flexible lifestyle where they are able to exercise choice and control over their lives and remain in contact with their family and friends. However, the lack of varied and stimulating activities means that peoples’ recreational and leisure needs are not always met. EVIDENCE: People living at the home said that they had a choice of when they go to bed at night and get up in the morning. This was seen to happen during the evening of the first day of this inspection visit and during the morning of the second day. At 6.30am on the second day, there were three people up and dressed. One said that she had always been an early riser and did not like staying in bed. Night staff said that another person, although not able to communicate her choices, had previously been a ‘morning’ person so as far as possible staff tried to adhere to her previous routine. The remaining person was restless and did not want to stay in bed. Other people came into the lounge at various times up until approximately 10.00am. When speaking about Brigshaw House, one person said that it was like ‘home from home’. Since the last inspection the manager has arranged for a priest to visit one person who is a practising Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 16 Roman Catholic. One person said that she appreciated the support and concern given to her by both staff and other people living at the home, following the death of her husband. In the Annual Quality Assurance Assessment (AQAA) completed by the manager before this inspection, it states that the home could be better at involving people living at the home in activities. Although staff had time to spend talking to people, there were no stimulating activities seen on both days, other than television or music. This was reflected in comments made by relatives in a recent quality assurance questionnaire. People said that entertainers occasionally visit the home, bingo is arranged about once a fortnight and the home has recently held a garden party, but they would like some trips and outings. The manager knows that this is an area that must be addressed and a discussion took place about ways of providing suitable activities for people with dementia. Visitors said that they were always made to feel welcome and people living at the home said that they could see visitors in the privacy of their own room, and that refreshments were available. The manager was aware of the importance of people maintaining contact with family and friends and described ways in which she is helping one person to maintain contact with her daughter in Australia. Senior staff were aware of how and when to contact advocacy services if needed. Staff were seen serving supper on the first day of this inspection and breakfast and lunch on the second day. The meals were nutritious and people were offered a choice. Complimentary comments were made about the food, which included, “We have lovely puddings”, “The meals are good”, “There is always a good choice” “If we like something it is put on the menu”. A discussion with the manager took place about the value of promoting and encouraging people’s independence and control by the introduction of tureens and gravy boats and replacing the institutional tea trolley with teapots, sugar basins and milk jugs on dining tables. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 & 18. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Written information on how to make a complaint is not in a format that is easy to read and understand by everyone in the home. Until all staff receive training on safeguarding adults there is no guarantee that abuse will be reported properly. EVIDENCE: Staff had a good understanding about the different types of abuse, but whilst some were clear about what to do if they suspected the management team of abuse, others were less sure. The manager said that training on adult abuse has been arranged for all staff. The home now has a copy of the Safeguarding Adults policy and procedure. People living at the home said that they felt that staff listened to what they had to say. There is a complaints policy displayed in the home but this needs updating to replace NCSC (National Care Standards Commission) with CSCI (Commission for Social Care Inspection). The timescale for responding to complaints needs to be identified in the policy. Since the last inspection the manager has placed a copy of the complaints policy, in large print, behind each person’s bedroom door. This is not suitable for everyone, particularly people using a wheelchair. A version using pictures and symbols may be of help to some people with dementia. A discussion took place about how to make this information available to people in a more user friendly way. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 18 The home keeps a log of all complaints. The manager was advised that to maintain confidentiality this must not be on display in the entrance of the home. Since the last inspection CSCI has received an anonymous complaint about the lack of hot water in the home. This was referred to the provider who dealt with the complaint in a satisfactory manner. This was not however logged in the home’s complaint log. The manager was advised that all complaints must be recorded. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 25 & 26. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Although further refurbishment is needed, the environment meets the needs of people living at the home. Infection control is well managed. EVIDENCE: Since the last inspection a ramp has been fitted to the front of the home to improve access for people in wheelchairs and those with poor mobility. The dining room and lounge areas have been decorated and a new carpet has been fitted. Much thought has been given to supporting people with memory loss to recognise their bedrooms. Pictures relevant to the individual now help people to identify their room. The manager is now looking at ways of making themed corridors so that people can recognise one corridor from another. This is good practice. Bathroom and toilet areas are now in need of refurbishment and consideration should be given to ways of making bathrooms less clinical, by the use of colour and pictures. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 20 Although the manager said that hot water temperatures in the home are checked regularly, the hot water supply in some rooms exceeded 50oc. The manager agreed to deal with this at once. Staff have a good understanding of infection control. There was liquid soap and disposable towels in all areas where clinical waste is handled. Watersoluble bags are now in use when laundering soiled linen. Two people living at the home said that their clothes were always ‘nicely pressed’. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Staff are well trained but at times the numbers of staff on duty do not always meet the needs of the people living at the home. EVIDENCE: On the first evening of this inspection there were only two staff on duty from 5pm – 10pm. During this time they had to give out medication, serve and clear away the teatime meal and prepare, serve and clear away supper in addition to their caring duties. This is unacceptable. On the 11th January 2007 a serious concerns letter was sent to the registered providers (owners) about evening staffing levels. A response was received stating that in future there would be a minimum of three staff on duty, along with kitchen staff cover until 7.00pm. The manager said that staff vacancies were being advertised in the local Job Centre, and during the inspection she received telephone calls from people interested in these posts. The manager was advised that there must be a minimum of three staff on duty throughout the evening shift, one of which, must be a senior care worker taking responsibility for the shift. People living at the home said that staff always made time for them, but were always busy. 25 of people living at the home are male but the entire staff group is female. This was discussed with the manager who said that she has had no response Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 22 from male workers for the vacant posts. The age range of staff is varied and there is a range of full time and part time staff. Supporting staff to achieve a National Vocational Qualification (NVQ) has been a priority for the home, with the result that 75 of staff have achieved the award at level 2 or above and a further 25 are currently being assessed. The home is now concentrating of supporting staff to complete mandatory training such as First Aid, Food Hygiene, Moving and Handling, Fire Safety, Safeguarding Adults and Use of the Hoist. All of the training is to be delivered by an external training provider. The manager has developed a simple plan showing which staff have completed this training. Advice was given on how to identify when updates are required. The manager said that the home’s induction programme has been amended in line with the Skills for Care induction standards. However the system proposed was a tick box approach with no way of assessing how the person had met the standards. The manager was given advice about Skills for Care workbooks, which can form a portfolio of evidence that can be used by staff at a later date. The recruitment records of a member of staff appointed since the last inspection were sampled and found to be in order, with the necessary checks having taken place. It is recommended however that application forms request a full employment history and when identifying referees the applicant should state in what capacity they know them. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, & 38. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Some practices in the home pose a potential risk to the health and safety of people living there. EVIDENCE: The manager has an NVQ level 4 in Management and City & Guilds 325/3 Advanced Care Management qualification, both of which meet the requirements of the management component for managers of care homes. The manager is aware that to meet the requirements in full she must complete an NVQ level 4 in Care, and is looking at ways of addressing this. The manager said that since the last inspection she is devoting more time to management duties rather than cooking and caring tasks, and that the appointment of new staff would help with this. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 24 Quality assurance surveys are distributed to people living at the home and their relatives. So that the home obtains the views and opinions of all concerned, it is recommended that the distribution include health care professionals. The returned surveys should be analysed and the results used to form part of the home’s development plan for the following 12 months. The home holds a small amount of money for safekeeping for some people living at the home. All transactions are recorded and the records of three people were sampled. It is recommended that whenever money is handed over on behalf of a person living at the home, a signature be obtained from the person handing over the money and the person receiving the money. This should be at the time of the transaction. The kitchen was clean and tidy and good food hygiene measures were taken in relation to food storage. The manager said that all staff are booked to attend training in food hygiene and fire safety along with other mandatory training. Bed safety rails were in use for one person on a divan type bed. The bed safety rails were not securely attached to the divan base and were capable of moving up and down the bed. There was information in this person’s care records about completing a risk assessment for the use of bed safety rails, but this had not been completed. This poses a potential risk to the person using them. The manager said that these are checked on a weekly basis by a handyperson who works across other homes in the group; she was not sure if this person had access to written safety advice on how to check this equipment. Care staff were unaware of the necessary safety checks, but said they would report any broken bed safety rails to the manager. Door wedges were used to prop open a corridor door and the office door. This practice poses a risk in the event of fire and must cease. The manager agreed to rectify this immediately. The manager has started a system of analysing accidents. Further advice was given on how this could be improved to identify any patterns or trends. Where an accident involving a person living at the home is not witnessed by staff, a record is not made of when the person was last seen and by whom. Brigshaw House DS0000001427.V347048.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 3 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Brigshaw House DS0000001427.V347048.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 OP7 Regulation 15 Requirement Care plans must give staff clear and specific instructions about how to meets all aspects of the resident’s health, personal and social care needs. This will make sure that people’s needs are not overlooked. Wherever possible care plans must be signed and agreed by the resident and/or their relative or representative. This will make sure that people are aware of the care they should receive. Previous timescale of 31/01/07 is unmet. Where nutritional and falls risk assessments show that a person is at risk a care plan must be developed to show the actions to be taken to minimise the risk. Care plans must be in place for people using pressure relieving equipment and bed safety rails. This will make sure that staff are aware of the actions they must Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 27 Timescale for action 30/11/07 2. OP9 13 (2) take. To make sure that guidelines from the Royal Pharmaceutical Society are followed, to prevent misuse and to reduce the risk of errors, the home must: • Return all medication no longer in use to the pharmacist for disposal. 31/07/07 3. OP12 16 (n) Make sure that medication dispensed by a pharmacist into one container is not transferred into another by staff at the home. A full and varied activity programme must be developed to meet the needs and abilities of people living at the home. This will make sure that people have access to a range of stimulating recreation and leisure activities. All staff must receive training on safeguarding adults. This will make sure that staff recognise and respond properly to any suspicions or allegations of adult abuse. All complaints about the home must be recorded. Decorating and refurbishment must continue and should include work on bathrooms and toilets. There must be sufficient numbers of staff on duty at all times. This will make sure that the needs of people living at the home are met. Previous timescale of 31/01/07 is unmet. Bed safety rails must not be put into use without a full DS0000001427.V347048.R01.S.doc • 30/09/07 4. OP18 13 31/10/07 5. 6. OP16 OP19 23 23 (d) 31/07/07 30/11/07 7. OP27 18 31/07/07 8. OP38 13 31/07/07 Page 28 Brigshaw House Version 5.2 assessment where all other options and the risks associated with the use of bed safety rails are considered. When bed safety rails are in use the home must follow the guidance stated in the Medical Devices Agency document ‘Advice on the safe use of bed rails’. This will make sure people using bed safety rails are not at risk. Previous timescale of 31/01/07 is unmet. 9. OP38 13 Where doors need to be propped open, a device must be fitted that activates door closure on the sound of the fire alarm. This will make sure that people are safe in the event of a fire. Previous timescale of 31/01/07 is unmet. 31/07/07 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 OP1 Good Practice Recommendations The statement of purpose and service user guide should be updated to reflect the actual care given. The format of both documents should be revised to make sure that it is suited to the needs of the people living at the home. This will make sure that everybody has information they can understand. Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 29 2. OP3 3. OP15 The home’s pre admission assessment should be recorded at the time that the assessment took place. The assessment record should give details about all aspects of the resident’s care needs and specify what support is needed. This will make sure that staff have accurate information on the care the person needs. The home should consider introducing tureens, gravy boats, and after a risk assessment process teapots, milk jugs and sugar basins on dining tables. This will promote and encourage independence and dignity. The home’s complaint policy should be updated and made suitable for the needs of people living there. This will make sure that everybody has information they can understand. The hot water supply to people’s bedrooms should not exceed 43oc. This will reduce the risk of burns and scalds to people living at the home. Application forms should request a full employment history. When identifying referees applicants should state in what capacity they know the referee. The distribution of the home’s quality assurance surveys should be extended to include people living at the home and health and other professionals. Feedback from the surveys should be analysed, the results published and used to form a development plan for improving the service provided. Staff rotas should show the senior person in charge of the shift. This remains unmet from the last inspection. When money is handed over on behalf of a person living at the home for safekeeping a signature should be obtained at the time from the person handing over the money and the person receiving the money. When an accident involving a person living at the home is not witnessed, a record should be made of when the person was last seen and by whom. This remains unmet from the last inspection. 4. OP16 5. OP25 6. OP29 7. OP24 8. OP27 9. OP35 10. OP38 Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brigshaw House DS0000001427.V347048.R01.S.doc Version 5.2 Page 31 - 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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