Inspection on 17/02/06 for Brigstock Manor

This inspection was carried out on 17th February 2006.

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

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

Other inspections for this house

Brigstock Manor 04/11/08

Brigstock Manor 07/11/06

Brigstock Manor 11/07/05

Brigstock Manor 11/01/05

Brigstock Manor 19/04/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Brigstock Manor 129 Brigstock Road Thornton Heath Croydon Surrey CR7 7JN Lead Inspector Michael Williams Unannounced Inspection 17th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 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. Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brigstock Manor Address 129 Brigstock Road Thornton Heath Croydon Surrey CR7 7JN 020 8684 1912 020 8684 3585 ann.denman@croydon.gov.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) London Borough of Croydon Ann Elizabeth Denman Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability over 65 years of age (0) of places Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2005 Brief Description of the Service: Brigstock Manor is a large residential establishment registered with the CSCI to provide personal care for up to 26 elderly service users on a permanent basis, and it has 7 respite, short stay beds. The home is owned and run by the London Borough of Croydon. The home is situated on a busy main road in Thornton Heath and is therefore close to public transport. The stated philosophy of the home is to provide a caring and homely environment for our service users and to endeavour to treat everyone equally regardless of their disability, gender or ethnic origins. Accommodation is on three floors, with the ground floor being used for respite care. Communal areas comprise small lounges and dining rooms with kitchenettes on each floor. There are bathrooms and toilets on each floor and other facilities include laundry, kitchen administration offices. The home has a large, enclosed garden to the rear and parking space to the side of the premises. Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 9:30 in the morning and included a tour of the premises; meetings with service users, with relatives and with staff and examination of a sample of the statutory records. The main purpose of this inspection was to monitor compliance with previous requirements. Any key standards fully met in the previous inspection were not reassessed in detail on this occasion. What the service does well: 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. Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 6 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 Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users are being assessed prior to admission so as to assure prospective service users that all their health and social care needs can be met when they are admitted. Whilst intermediate care is not provided respite care is available and again the CSCI was able to confirm that suitable arrangements are in place to assess short stay service users’ needs prior to admission to ensure that even in the short term their needs are clearly identified. EVIDENCE: Key standard 3 was assessed as fully met in July 2005 and there was no evidence to suggest that it cannot remain met. Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Care Plans are in place for each service user. This means their health and personal care needs are clearly set out action plans to ensure their personal goals can be fully met in this care home. Medication can either be administered by the care staff or staff will support service users to hold and administer their own medication in order to maximise their independence. Service users are treated with respect and dignity. EVIDENCE: Key standards were assessed as fully met in July 2005 and there was no evidence to suggest that they cannot remain met. Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home provides a comfortable setting for service users to engage in social and cultural activities as they choose and in accordance with their expectations of the home. The staff assist and encourage service users to lead as fulfilled lives as they wish or their frailty allows. Service users are encouraged and given every opportunity to maintain contact with family and friends and the community. A full and wholesome menu is available for all service users to ensure their health and well being and to provide them with a diet that suites them including those who wish for meals from other cultures/nations. EVIDENCE: Key standards were assessed as fully met in July 2005 and there was no evidence to suggest that they cannot remain met. Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Arrangements are in place for service users and their representatives to either complain or compliment the service. Effective procedures are in place to deal with complaints. Service users confirm that with these arrangements in place they are confident their opinions and concerns are dealt with in a professional and thoughtful manner. Arrangements are also in place to protect the vulnerable service users. EVIDENCE: No complaints arose during the course of the inspection; in contrast many people complimented the home and staff team. One complaint was recorded but the file containing the record of complaints was rather full, and there were at least three files labelled ‘complaints’ so it was not easy even for the home’s staff to identify and count recent complaints – a simpler record is suggested; the incident book for example would suffice for the purposes of CSCI inspection and is already labelled ‘incidents and complaints’ but it is not in use for recording complaints. In respect of the protection of vulnerable person from abuse staff were not always clear about the term ‘whistle-blowing’ – although they were clear about reporting untoward incidents to managers or agencies outside the organisation such as the local Social Service Department or CSCI inspectors. As the term whistle-blowing may not be familiar to staff whose first language is not English a clearer explanation should be given for this. In other respects the procedures for protecting vulnerable service users is satisfactory; the home has a copy of the local authority’s procedures for dealing with allegations of abuse but no such issues have arisen since the previous inspection. Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Service users live in a safe, well-maintained and comfortable environment. This is a purpose built, but rather aged, care home and is subject to ongoing refurbishment. It was clean and comfortably warm at the time of inspection. EVIDENCE: This local authority care home is now rather old and showing its age and is in need of regular maintenance to keep it in good working order. Communal areas are pleasantly decorated. The individual rooms, though not spacious, are adequate and are fitted standard bedroom furniture and fittings. Minor points noted include an old metal bed-frames and worn furniture in some locations, such as the arms of chairs in bedrooms and minor damage to walls. This is a large care home but the small units make it a homely environment for the small groups of service users. The home was generally clean and tidy at the time of inspection but hygiene problems were identified in the kitchen area. Storerooms and the staff room need to be kept tidier and storage space extended to accommodate fresh vegetables as noted by a recent Environmental Health visit. The inspector could not confirm that both freezers were in good working order. The home’s digital thermometer and the Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 12 inspector’s readings indicate that the freezers are not maintaining the correct temperature (-18OC). The kitchen floor was not thoroughly clean in all areas of the floor. The kitchen does not have a cleaning schedule to identify when, how and by whom cleaning work is done. ‘Fridges in the service users’ kitchenettes are damaged and not suitable for cold storage of food. Unless the home can demonstrate that their existing digital thermometer is in full working order and measuring temperatures accurately a new one is recommended. The visiting Environmental Health Officer made several requirements and recommenddations – to record hot food temperatures, clean fans, and clear rubbish bin area and bring fresh vegetables within the kitchen to record the temperature of the hot trolley when used to serve food and to reduce the size of large joints of meat – the cook explained how these requirements have been now been met. Despite these shortcomings in the kitchen the service users say the meals are very good with a nice range of choices offered. These include meals designed to meet the needs of ethnic minority service users. On the day of inspection the meals included fish, fried or steamed or poached egg - each served with vegetables – there was also an Asian meal for the several Asian ladies in the home. In the laundry, the dryer is broken and should be replaced without delay. Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Staffing levels and skills mix appeared adequate for the current care needs of service users so as to ensure their wide range of social and health needs could be met. A number of temporary staff including agency staff are still being employed in the home but service users appear ‘safe in their hands’ as required by standards in this section. EVIDENCE: There were 31 residents in the home and there were 4 carers plus two senior staff also assisting in the care of residents; plus the manager and numerous ancillary staff. Staff records are now being transferred to the home as required by Regulation Two requirements are re-stated - to employ adequate numbers of permanent staff without unreasonable delay because agency are still employed regularly in this home and secondly to ensure all staff records in respect of staff recruitment are available for inspection by CSCI because the home is still looking to the head office to keep documentation in the home itself as required by regulation. Whilst interviewing staff it was apparent that they are well informed about their duties and are highly regarded by the service users. However, two points requiring attention did arise; staff were not clear about the meaning of the terms ‘fire drill’ and ‘whistle-blowing’. The staff nevertheless do receive fire drill practices as recorded in the fire records and were aware of the procedures for reporting allegations of abuse of vulnerable people – the lapse therefore appears to be one of language in so far as not all staff in this home have English as their first language. A recommendation is made to sure staff are clear about technical terms and jargon - particularly in matters of service user safety. Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 35 38 With a ‘people centred’ approach it was clear that this home is being run in the best interests of the service users and certainly the service users thought so. The manager is registered with the CSCI as a person competent to run this home in accordance with its stated aims and objectives and in the best interests of the service users. The home is well managed; including finances and medication for example, and is safe for service users. EVIDENCE: Service users throughout the home were full of praise for the home, its staff and management. This is a competently run care home. The registered manager has been assessed by the CSCI as competent and fit to manage this home. The home is managed so as to ensure the health and well being of the service users but the kitchen needs improvement as outlined under the environmental section of this report. Money records were checked in some detail and found satisfactory. Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 16 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 OP27 Regulation 18(1)(b) Requirement Staff: The manager advised the inspector that the home still has several staff vacancies and is reliant upon temporary agency staff. The home is required to employ staff who are not temporary in sufficient numbers to meet the needs of service users. The CSCI acknowledges that an action plan is in place to address this requirement within a reasonable timescale. Records: Staff records need to contain the details listed in the Regulations and Schedules including details of police and POVA [Protection of Vulnerable Adults List] checks. This remains an outstanding requirement. Kitchen: The kitchen must be maintained in an hygienic condition and all equipment, including cold storage units maintained in proper working or be replaced without delay. Laundry: All equipped must be properly maintained including dryers. Timescale for action 30/08/06 2. OP37OP29 17 30/03/06 3. OP26OP19 N/A 30/03/06 4 OP19 N/A 30/03/06 Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 17 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Brigstock Manor DS0000043307.V266116.R01.S.doc Version 5.0 Page 19 - 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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