Inspection on 04/10/05 for Brigshaw House

This inspection was carried out on 4th October 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 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 WF10 2HN Lead Inspector Stevie Allerton Announced 04 October 2005 09:30 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 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Brigshaw House Address 2 Brigshaw Lane Allerton Bywater CASTLEFORD WF10 2HN 0113 286 8421 0113 286 8421 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) Cymar Care Homes Limited Mrs Pauline Barker Care Home 21 Category(ies) of Dementia (21), Old Age (21) registration, with number of places Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20 May 2005 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 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced in advance and was carried out by one inspector over the course of one day. This was the second inspection to take place during the year ending 31st March 2006; the previous inspection was unannounced and took place in May. Posters and comment cards were sent to the home, along with other preinspection material, to inform service users, their relatives and other visitors about the forthcoming inspection, and invite comments to be made about the service. Thirteen comment cards were returned by relatives, plus one by a District Nurse and a letter was left for the inspector’s attention. They were all very positive and expressed high levels of satisfaction with the home. Records and policies were looked at during this inspection, the findings checked out with service users, relatives and staff. The inspector had lunch with the service users in the dining room, which provided opportunity for discussion about daily life in the home. A tour of the premises was also carried out. What the service does well: The staff team have created a really good atmosphere at this home. Visitors are greeted and welcomed on arrival and appear to be made to feel at home whilst they are visiting. Relatives who used the feedback cards or wrote, said such things as: “there is a family atmosphere”, “a very special place”, “I can really enjoy visiting my mother here”. Service users and relatives said that they liked the staff and felt that care was given in “a kind and sensitive manner”. Visitors find the staff approachable, particularly the Manager, and expressed confidence that they could discuss any concerns directly with her. The staff team also work well with other health care professionals, to ensure a good standard of care. The building is comfortable and well maintained and there are no unpleasant odours. The garden is particularly appreciated by many of the service users. Meals are nutritious and well presented, with sufficient variation and choice for the service users, who praised the home cooking. Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 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 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 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) None of these standards were looked at on this visit. EVIDENCE: Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 Page 9 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 & 9 There is a co-ordinated approach to care planning and the staff deliver personal care in accordance with the agreed plans. The staff team work well with health care professionals to ensure that health needs are met. Medication is stored and administered safely. EVIDENCE: Care plans for three service users with a range of care needs were examined, the findings verified in discussion with the service user, where possible, or their relatives and staff. One person had been admitted to the home three weeks earlier; an assessment of care needs had been completed by the Manager before admission and the initial care plan was put in place by the third day, signed by a relative and to be reviewed after the first month. The inspector spoke to the service user, who said she was happy with the level of support the staff were able to give her, and that they treated her kindly. A GP visited the home during the inspection, in response to a request from the staff to see a service user who was unwell. It was clear that he had a good rapport with the staff, who felt that he provided a good standard of health care Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 Page 10 to the service users. District Nurses are also in regular contact, one of whom sent a comment card expressing a high opinion of the home and the staff team. There was evidence within the care plans that appropriate referrals are made to specialist health care professionals where necessary, including those specialising in infection control and that the staff are willing to work with specialists to ensure continuity of treatment. Medication storage, administration and recording were inspected. There is a dedicated treatment room where the medicines trolley is kept securely when not in use. The trolley was well organised, with monthly supplies of predispensed medicines in blister packs, recorded on the supplied MAR (Medicines Administration Record) sheets. There is also a system for recording controlled drugs, which are stored separately. Some omissions were noted on the MAR sheets, where staff had not initialled that the medicines were given. Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 Page 11 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) 12, 13 & 15 The home meets service users’ preferences well. There are opportunities for social and recreational activities, which service users say are good. A lot of effort is made by the Manager and staff to engage relatives in the daily life of the home, which they do by creating a welcoming atmosphere. Food is one of the best features of the home. EVIDENCE: Service users are given opportunities to visit the home prior to admission, to experience a day’s normal activity, for example. If this is not possible, then the Manager spends time with their relatives, explaining the ethos and routines of daily life. Service users who were spoken to at lunchtime said that they enjoyed the programme of activities, but did not feel obliged to join in if they didn’t want to. Some enjoy the garden and had spent a good deal of time in the summer sitting under the gazebo, said to have been a very popular addition to the garden. The home was busy, as usual, with visitors coming and going during the inspection. Relatives and friends of service users are seen as an important part of daily life and encouraged to be as involved in their relative’s care as Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 Page 12 much as they wish. In turn, their presence creates a lively and interesting atmosphere within the home. The inspector had lunch with service users in the dining room, which was a pleasant and sociable setting. The meal was well presented, tasty and appetising. Service users appreciate the home cooking that is provided and said that the variety, choice and presentation of meals was good. The puddings and home baked cakes were especially popular. The menus supplied reflected sufficient variation, with some traditional dishes featured in response to service users’ preferences and requests. Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 17 The home has a proactive approach to complaints management. The Manager is also willing to tackle poor practice that might compromise service users’ rights. EVIDENCE: The complaints procedure is readily accessible to everyone in the home and the Manager has a philosophy of trying to resolve niggles and concerns before they grow into formal complaints. There have been no complaints logged during the last 12 months. Comment cards returned by relatives indicated that people were confident in the home’s ability to respond to concerns. All said they knew about the complaints procedure. The staff are aware of service users’ legal rights and their own responsibilities as carers to protect their rights. This has been demonstrated through a recent incident involving the covert administration of medication. The member of staff concerned was reported and disciplinary action taken, resulting in a dismissal. Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20, 23, 24 & 25 The environment is comfortable, homely and well looked after. Service users are able to arrange their rooms and personalise them as they like, which helps people to feel more at home. There is good attention to repairs and routine maintenance, so the environment is safe. Staff have the right equipment they need to do their job. EVIDENCE: Maintenance records were available, showing when mechanical and electrical systems, for example, had been checked. A recent report from the Fire Officer, following his visit in September, stated that the home meets the current standards for fire safety. A number of bedrooms were seen during the inspection, all of which were well decorated and furnished. One of the ground floor rooms had recently been refurbished, the new lights being a pleasing addition. No unpleasant odours were detected anywhere in the home. Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 Page 15 All laundry is now done in-house; the washing machine is equipped with a sluice cycle for soiled linen and there is a gas-powered tumble drier installed. The garden is a very positive feature of this home and is used by some of the service users on a daily basis. Even for those who cannot easily get out to enjoy it, there are good views from the windows; the visiting wildlife is a source of pleasure for many. Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 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) 30 The home needs to ensure that all training is recorded, so that it can be proved that certain mandatory training is taking place at the correct intervals. There is a problem in moving forward with NVQ (National Vocational Qualification) training, which is out of the hands of the Manager. Staff supervision is in place, aimed at helping the care staff to develop in their role. EVIDENCE: Training records were looked at for individual staff members. There were gaps in the records and it appeared that certain mandatory training had not taken place. Records were available elsewhere, e.g., a note in the diary when a Moving and Handling refresher course was booked, but this did not suffice as a record as it did not show which staff had attended. Six of the care staff are registered for NVQ training with Leeds Social Services, but this has had to be put on hold due to the shortage of NVQ Assessors. A wall planner shows when staff supervision has taken place and is due; this is being co-ordinated by the Deputy Manager, who described the areas covered in supervision meetings. Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 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) 35, 37 & 38 Service users who have their money looked after at the home are protected by a robust system of recording and safe storage. There is good attention to health and safety matters in the home; the staff are well trained and the practices observed on the day reflected this. More attention is needed to make sure the records reflect the practice. EVIDENCE: The home charges extra for such services as chiropody and hairdressing; the costs of these are agreed with the service user and/or their relatives and there is a copy of the contract in the service user’s file. The home adheres to the Leeds City Council Code of Practice regarding the management of personal allowances, a copy of which was available. There are suitable records of monies deposited in the office for safe keeping, with a simple system of accounting that appeared to be accurate. Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 Page 18 Six care staff have recently completed a Health and Safety course, a distancelearning package through Park Lane College. The two handymen also did the course, which covered Fire Safety, Moving and Handling, COSHH regulations, Risk Assessments and Hygiene. The inspector observed some examples of good practice relating to food hygiene, plates covered until they were delivered to the table, etc. Fire practices had been recorded when they took place for the staff; these were regular and involved practicing various scenarios. However, there were no records available that showed whether weekly fire alarm tests had been carried out. Other records were examined during the course of the inspection that relate to Health and Safety: • Staff training records and course workbooks • Accident reports • Risk assessments • Fire evacuation plans Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 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 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x 3 x x 3 3 3 x STAFFING Standard No Score 27 x 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x x x x x 3 x 2 3 Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 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. 2. 3. Standard 9 30 38 Regulation 13(2) 18(1) 17(2) Requirement All staff must adhere to the procedure for recording the administration of medicines. The registered person must ensure that full records are kept of all staff training. Fire alarm tests must be carried out as advised and records kept. Timescale for action Agreed at the time of inspection. By 31.12.05 By 31.12.05 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 Brigshaw House 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 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 20051004 Brigshaw House AN Stage 4 S1427 V202235 J52.doc Version 1.40 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!