CARE HOMES FOR OLDER PEOPLE
Brincliffe Towers Brincliffe Edge Road Sheffield South Yorkshire S11 9BZ Lead Inspector
Janis Robinson Unannounced Inspection 13th December 2005 09:00 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 Brincliffe Towers DS0000046508.V261501.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. Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Brincliffe Towers Address Brincliffe Edge Road Sheffield South Yorkshire S11 9BZ 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) 0114 255 2821 0114 255 2821 Ash House (Yorkshire) Limited Ms Moira Elliss Layne Care Home 35 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24), Old age, not falling within any other category (11) Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. All 24 DE(E) beds are registered `or MD(E)` and are sited in a separate wing. Service users may also be aged 60-65 years. Date of last inspection 6th April 2005 Brief Description of the Service: Brincliffe Towers is a care home providing personal care and accommodation for thirty-five older people, including care for twenty-four service users with dementia. The home is privately owned, and is located in a residential area of Sheffield with nearby access to public transport. The home is a large old detached house with a modern annexe attached and has very pleasant well-established gardens, which overlook Chelsea Park. There is a small car park to the front of the house. All of the bedrooms are single although two are registered, as doubles should there be a request to share. Seven rooms have an en-suite facility. There is a passenger lift. Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 3 hours from 9.00 am to 12.00 pm. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, rotas, staff training, health and safety, medication and fire records. Interactions between staff and residents were observed. Six residents, a proportion of staff and two visitors were spoken with. Discussions with the homes manager took place. The majority of standards were assessed and met at the last inspection. What the service does well:
All of the comments made by residents were positive. Residents said ‘I am well looked after’’ and ‘the staff are kind’. Residents had been provided with a service user guide, to give them information about the home. Trial visits to the home, to enable prospective residents and their representatives to make an informed decision, were encouraged. A care plan had been developed for each resident, to give staff the information needed to meet assessed needs. Access to health care professionals was available, to maintain residents health. Residents confirmed that the staff were respectful towards them. The routines at the home were flexible, some activities were available, and residents were able to choose how to spend their day. There was an open visiting policy, to encourage contact with family and friends. All residents said the food provided was ‘very good’ and confirmed that choices were offered. A varied menu was provided. There was a complaints procedure, each resident had been provided with a copy to inform them of their rights. All spoken with said they had confidence in the staff at the home, who would listen to any concerns and take them seriously. Adult protection procedures were in place. The environment was well maintained, in the main. The home was clean and free from odours. Homely touches were provided in communal areas to create a comfortable environment. Agreed levels of staff were being maintained. The home had a commitment to National Vocational Qualifications (NVQ), to ensure staff had the skills needed to meet the needs of residents. Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 6 Residents’ finances were safely managed. Health and safety systems were in place at the home, fire equipment had been checked and serviced. What has improved since the last inspection? What they could do better:
One care plan examined did not contain any information relating to residents wishes regarding funeral arrangements, to ensure these were carried out. Aspects of the environment required some redecoration and repair, to maintain standards. 50 of the care staff team had not achieved NVQ level 2 in care. Regulation 26 reports by the registered provider, as part of the homes monitoring systems, did not take place at the required frequency. Staff supervision, to support and develop staff, did not take place at the required frequency. Some staff required refresher training in aspects of mandatory training, to ensure their skills were kept up to date. Moss was apparent in the enclosed patio garden, which posed a potential slipping hazard.
Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 7 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. Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5 The Statement of Purpose and Service User Guide provided sufficient information for prospective service users to make an informed decision about admission to the home. Trial visits to the home were encouraged. EVIDENCE: The homes Statement of Purpose and Service User Guide were informative and up to date. Copies of the service user guide had been provided in each bedroom, to give residents information about the home. A number of residents spoken to said that prior to admission they were encouraged to visit the home to meet people, see the facilities available and sample the hospitality. Staff confirmed that prospective residents were able to visit the home and spend the day, in order to inform their choices. Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Each resident had a care plan, to give staff the information needed to ensure all care needs were met. Residents’ health care was monitored and access to health professionals was available. Medication was safely stored, recorded and administered. Residents were treated with respect and privacy was respected. Each care plan contained a section on death and dying, to ensure residents wishes were sought and carried out. This section had not been completed in one plan checked. EVIDENCE: Care plans contained information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. Moving and handling, and falls risk assessments had been undertaken for all residents to keep them as safe as possible. Care plans identified that a range of health professionals visited the home to assist in maintaining health care needs. Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 11 Medication was securely stored and Medication Administration Records were up to date. Since the last inspection the manager had undertaken monthly monitoring checks of medication systems, to improve practice. Staff were observed interacting well with service users. Residents spoken to said staff were ‘kind’ and ‘helpful’ and their right to privacy was always upheld. The wishes of residents were sought regarding death and dying, which were recorded in plans to ensure these were carried out. Plans also recorded where this information would be sought from family at the appropriate time. One plan inspected did not record any information regarding dying and death. Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 A variety of activities were available to residents. There were no restrictions on visiting times and residents were able to receive visitors in private. A varied menu was provided. EVIDENCE: Since the last inspection the range of activities on offer had improved. External entertainers included music for health, music and movement and arts and crafts. Music for health was found to be especially beneficial to residents in the EMI wing. One resident that did not normally communicate well played the violin in these sessions, a further resident, that was not normally very vocal, enjoyed singing to the music. The two visitors spoken with made positive comments. They confirmed that they were able to visit at any time, and that they could always see their relative/friend in private, if they chose. They informed the inspector that the resident they were visiting was ‘very happy’ at the home. All of the residents spoken to said the food provided was good, they said the food was ‘plentiful’. Choices were offered. The homes menu was varied. Staff had access to food supplies at all times, to cater for residents needs.
Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened to and taken seriously. An Adult protection procedure was in place. EVIDENCE: Each resident and representative had been provided with a copy of the homes complaints procedure contained within the service user guide. This contained relevant detail and informed the reader of who to contact outside of the home to make a complaint, should they wish to do so. All of the residents said they had no concerns and could go to the manager and staff to sort out any worries they had. The home kept a record of complaints. The home had not received any complaints since the last inspection. The homes adult protection procedure contained all of the required information, to ensure staff were fully informed of the action to take if any allegation was made. Since the last inspection the majority of staff had been provided with adult protection training. Further training had been organised to take place in January 2006 for all remaining staff. Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 22 and 25 The location and layout of the home was suitable for its stated purpose. Communal areas appeared comfortable. Further aids and adaptations were required to fully meet residents’ needs. Some redecoration work was required to maintain standards. EVIDENCE: The homes ground floor dining and lounge areas appeared comfortable and were provided with pictures and ornaments that created a homely environment. They were, in the main, well decorated. Since the last inspection blinds had been provided to an identified toilet to afford privacy. Exposed pipe work in one bedroom had been covered to minimise risk. The wooden skirting boards were badly scratched and marked in the residential wing dining and lounge areas. Some tiles in the lounge hearth were broken or missing. Cladding to pipes in the dining room was torn and dirty. The corridor
Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 15 carpet in the EMI wing appeared marked in places. Plastic chairs had been left upturned in the patio area, which created an uncared for appearance. Plans had been in place to provide a hoist to assist moving and handling in the residential wing. However, the hoist in the EMI wing had broken, and replacement of this hoist had taken priority. Plans to provide this facility in the residential wing must be acted upon to fully meet all residents’ needs. Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 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 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 and 28 Staff were employed in sufficient numbers to meet the needs of residents in accordance with agreed staffing levels. Staff undertook NVQ training. EVIDENCE: The manager stated that agreed staffing levels were being maintained. This assisted in making sure that residents’ needs were met. Residents spoken to said that staff were kind and helpful. The homes rota indicated that agreed levels of staff were maintained. 50 of the care staff had not achieved NVQ level 2 in care. Of the 23 care staff, six staff had achieved level 2 in care. A further eleven staff were undertaking the award at level 2. It was anticipated that these staff would have completed their training by the end of March 2006. Once these awards have been achieved, required targets will be met. Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 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 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): 33, 35, 36 and 38 A quality assurance system was in place to obtain the views of residents and their representatives. Provider reports were not undertaken to ensure the home was monitored efficiently. Residents’ monies were handled safely. Staff supervision did not take place at the required frequency. Health and safety systems were maintained. Some staff required refresher training. Moss to the enclosed patio area posed a possible tripping hazard. One lock to the EMI wing was broken. EVIDENCE: Surveys were undertaken with residents and their representatives to ensure they were consulted formally, and their views taken into account. Whilst the provider visited very regularly, formal monthly monitoring visits and records were not undertaken at the required monthly frequency. These are
Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 18 important as they ensure a systematic and organised monitoring of the service takes place. Residents’ monies were handled safely. Records were maintained of every transaction, and recorded details of credits, debits and balance. Receipts were retained. Money was stored securely. The manager and administrator audited residents’ accounts on a monthly basis to ensure safe systems were maintained. Staff supervision, to support and inform staff, was not undertaken at the required frequency of six times each year. A health and safety system was in operation, to ensure residents were safe. Fire fighting equipment was checked and serviced. Fire records indicated that staff had participated in a practice drill at the required frequency to ensure they were aware of how to respond in an emergency. Records of mandatory staff training had not been kept up to date. Some staff were out of date with food hygiene and moving and handling training. Moss covered part of the enclosed patio area, posing a risk. One lock to the EMI wing was broken, which could compromise residents’ safety. The inspector acknowledges that this had been reported for repair. Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X 1 X X 3 X STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 X 2 Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 20 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 OP11 Regulation 12 Requirement Care plans must record information on residents’ wishes regarding dying, death and funeral arrangements. The marked and scratched skirting boards must be redecorated. The torn and dirty cladding on pipes in the residential wing dining room must be replaced. The broken and missing hearth tiles in the residential wing lounge must be replaced. The carpet in the EMI wing corridor must be replaced. The discarded chairs in the patio area must be removed. Bathrooms and toilets must be refurbished and suitable adaptations installed to assist residents that are old, infirm or physically disabled. (Previous timescales of 30/11/03 and 01/08/05 not met) Visits by the registered provider must take place as detailed in Regulation 26 of the Care Homes Regulations, and comprehensive reports must be provided.
DS0000046508.V261501.R01.S.doc Timescale for action 31/01/06 2 3 4 5 6 7 OP19 OP19 OP19 OP19 OP19 OP22 23 23 23 23 23 23 28/02/06 31/01/06 31/01/06 31/03/06 31/01/06 31/03/06 8 OP33 26 31/01/06 Brincliffe Towers Version 5.0 Page 21 9 10 11 12 OP36 OP38 OP38 OP38 18 13 13 18 (Previous timescale of 01/06/05 not met) Staff supervision must take place at the minimum frequency of six times each year. The moss must be cleared from the patio area. The broken lock to the EMI wing must be repaired. An audit of staff mandatory training must be carried out. Where gaps are identified, training must be provided. Staff training records must be maintained up to date. 31/01/06 31/01/06 31/12/05 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP28 Good Practice Recommendations 50 of the care staff must be trained to NVQ level 2 in care by 2005. Brincliffe Towers DS0000046508.V261501.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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