CARE HOMES FOR OLDER PEOPLE
Brincliffe Towers Brincliffe Edge Road Sheffield South Yorkshire S11 9BZ
Lead Inspector Sue Turner Unannounced 06 April 2005 08:15 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. Brincliffe Towers Version 1.10 Page 3 SERVICE INFORMATION
Name of service Brincliffe Towers Address Brincliffe Edge Road Sheffield South Yorkshire S11 9BZ 0114 255 2821 0114 255 2821 Not Available Ash House (Yorkshire) Limited 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) Ms Moira Elliss Layne PC Care Home only 35 Category(ies) of DE(E) Dementia - over 65 (24) registration, with number MD(E) Mental Disorder - over 65 (24) of places OP Old Age (11) Brincliffe Towers Version 1.10 Page 4 SERVICE INFORMATION
Conditions of registration: 1. All 24 DE(E) beds are registered or MD(E) and are sited in a separate wing. 2. Service users may also be aged 60-65 years. Date of last inspection 21 September 2004 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 Version 1.10 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day between 8.15am and 3.30pm. A tour of most parts of the building and grounds was carried out. A number of records, relating to those living in the home and management paperwork were checked. Time was spent talking with groups of service users in communal areas and individually with two service users. As the home accommodates people living with dementia, time was spent observing the interaction between staff and service users. The provider, manager and six members of the staff team were also consulted. What the service does well: What has improved since the last inspection?
Service users care plans had more detailed information relating to health, personal and social needs. The manager had consulted with service users, relatives and professionals about any improvements that could be made and resulting from this a new activities programme had been introduced. Activities that were suitable to the service users preferences and capabilities were on offer. Service users spoken to about the activities were enthusiastic and contented with what was on offer. A number of bedrooms and some communal areas had been re decorated improving the general appearance of the home. Ancillary staff had been recruited bringing numbers up to an acceptable standard and resulting in the cleanliness of the home improving. Brincliffe Towers Version 1.10 Page 6 All staff were being given formal supervision by their line manager, which they said assisted them to carry out their role more capably. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brincliffe Towers Version 1.10 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 Brincliffe Towers Version 1.10 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 2 3 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. Staff assessed all prospective service user needs by visiting them prior to admission. EVIDENCE: The homes Statement of Purpose and Service User Guide were informative and up to date. Three service user files were checked and each contained a copy of their written contract. A number of service users spoken to said that prior to admission staff from the home visited them to assess their needs and give them information relating to the home. They were also encouraged to visit the home to meet people, see the facilities available and sample the hospitality. Brincliffe Towers Version 1.10 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 and 10 Care plans detailed a significant amount of information relating to health, personal and social needs. Accident recording and follow up care was inadequate. Where cassettes were not used there were discrepancies in the medication administration records. Medication, which was not signed for at the time of administration, was placing service users at possible risk or harm. Overall service users were treated with respect and their privacy was upheld which helped to make them feel comfortable and ‘at home’. EVIDENCE: Three service users plans of care were checked. Each set out individual needs and the action required by staff to ensure those needs were met. Discussion with service users identified that a range of health professionals visited the home to assist in maintaining health care needs. One service user seen had a dressing that required changing. When determining the details relating to the care of the wound, it was found that although an accident form had been completed there was no record of the dressing being applied and any subsequent wound care to be given. This could have caused problems for the service user.
Brincliffe Towers Version 1.10 Page 10 Prescribed medications were checked for two service users. These were kept in lockable trolleys and administered by designated staff. This promoted safety of service users. The majority of medications were dispensed in cassettes. For one service user, a cassette was not used and the number of tablets present did not tally with medication administration record (MAR) sheet. A check of a number of MAR sheets showed that staff did not always sign for medication at the time of administration. This practice places service users at possible risk and increases the likelihood of errors. Service users spoken to said that staff at the home respected their privacy and dignity, however one member of staff was observed speaking inappropriately within ear shot of service users. The inspector spoke to the member of staff about this. Brincliffe Towers Version 1.10 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 14 and 15 The routines within the home were flexible and service users were able to spend their day as they wished. Activities that matched preferences and capabilities were on offer. There were no restrictions on visiting times and service users were able to receive visitors in private. A good choice of menu was offered and special dietary needs were catered for. EVIDENCE: In response to a previous requirement discussions had taken place with service users to establish their preferences regarding activities inside and outside the home. Service users spoken to said they enjoyed a range of activities available within the home and trips outside the home were planned for the nicer weather. One service user said they particularly looked forward to the church service held each month. Throughout the day friends and family were seen visiting freely and being offered hospitality, which creates a home that people want to visit. Bedrooms seen were personalised and observation of the interaction between service users and staff confirmed that personal autonomy and choice were well considered. Breakfast was observed being served in the EMI dining room. Choices were offered and assistance given as required. The meal looked appetising and was enjoyed by service users.
Brincliffe Towers Version 1.10 Page 12 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 and 18 The homes complaints procedure was clear and accessible. Complaints made were listened to and action taken to deal with any issues promptly. Staff had limited knowledge and understanding of adult protection issues, which could possibly place service users at risk of harm or abuse. EVIDENCE: The home had a record of any complaint/concern raised by services users and/or their family. Evidence was seen that appropriate action was taken to rectify any matter. CSCI had received one complaint, regarding the service since the last inspection. This complaint investigation had not been fully completed despite the provider trying very hard to resolve the issues raised. The home had a procedure on adult protection. The homes abuse policy stated that any allegations/incidents of abuse were referred immediately to Social Services Adult Protection procedures. There had been no allegations of abuse reported at the home. When interviewed a number of staff were unsure about adult protection policies and procedures and what their responsibilities were in relation to the protection of service users. They said that they had watched a video about adult abuse but had not received any formal training. This lack of clarity indicated that the training had not been fully effective. Brincliffe Towers Version 1.10 Page 13 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) and 26 19 21 23 24 25 The location and layout of the home is suitable for its stated purpose. Service users bedrooms met individual’s needs in a comfortable and homely way. The absence of curtains or blinds to the toilet windows does not take into consideration the privacy and dignity of service users. Sufficient and suitable bathrooms and toilets, which had adaptations installed to maximise independence were not made available. EVIDENCE: The grounds around the home were very welcoming and service users said that they could easily access them should they wish. All areas of the home were clean and tidy. Lounge and dining areas were domestically furnished. Three bedrooms were checked in detail and many others seen, all were comfortable and homely. Service users spoken to said that they had all they wanted in their rooms. Exposed pipe work was seen in one bedroom causing a potential health and safety risk. The housekeeper was aware of the areas within the home that required decoration and work was prioritised accordingly.
Brincliffe Towers Version 1.10 Page 14 Refurbishment work to the bathrooms and toilets that had been required at previous inspections had not been completed. Consequently the majority of service users were unable to utilize bathrooms/toilets. Curtains/blinds that would offer privacy to the service users were not fitted to the toilets in the DDE wing. Brincliffe Towers Version 1.10 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 28 29 and 30 Staff were employed in sufficient numbers to meet the needs of the service users. Service users felt safe at the home. Full recruitment checks were carried out which contributed to the protection of service users from abuse. Staff had undertaken training in various subjects. The method of teaching/training did not ensure staff were fully skilled and competent to carry out all their duties. EVIDENCE: The manager stated that agreed staffing levels were being maintained. Service users spoken to said that staff were kind and helpful. Two newly recruited domestics meant that ancillary staffing levels were satisfactory. Staff spoken to and three files checked confirmed that thorough recruitment procedures were carried out prior to employment being offered. Two members of staff had completed NVQ training and a further eleven were undertaking the qualification. All staff undertook an induction programme, which the manager stated, met the National Training Organisation (NTO) specifications. All training undertaken by staff was in the form of watching a video and answering a questionnaire. The skills and knowledge demonstrated by a number of staff was limited, in certain areas, for example adult protection procedures. This indicates that the training was not fully effective, leaving staff and service users vulnerable. Lack of external training meant that competencies were not independently measured to assess whether they were in line with agreed standards. Brincliffe Towers Version 1.10 Page 16 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) 33 36 37 and 38 The published results of the quality assurance survey demonstrated a commitment by the manager to meet the aims and objectives of the home. An equal commitment, to carry out Regulation 26 visits was not shown by the responsible individual. Staff were appropriately supervised on a continuous basis. Omissions from records kept at the home could pose a potential risk of service users not receiving appropriate health care (see standard 7). Arrangements for all staff to undertake fire training were not satisfactory placing service users and staff at a possible risk of harm. EVIDENCE: Since the last inspection the manager had sent out questionnaires to service users, professionals and relatives to ascertain their views of the home. Information had then been collated and appropriate action taken which had improved the service. Regulation 26 visits were carried out, but these were not at the obligatory intervals nor did they provide the information required by the regulations. Six staff members were spoken to and all said that they had
Brincliffe Towers Version 1.10 Page 17 received regular, formal supervision from their line manager, which gave them confidence in carrying out their duties. Supervision was planned and recorded. A number of records were checked; in the main these were clear and up to date. Fire records confirmed that weekly fire checks, alarm systems, extinguishers and emergency lighting had been completed as necessary. Not all staff had received fire practices and/or drills as required by the homes policy and procedures. The manager stated that a previous requirement requesting confirmation that fixed electrical systems had been serviced had not been actioned. Risk assessments were seen on individual service user files, these had been reviewed and updated as necessary, thereby promoting the safety of service users. Brincliffe Towers Version 1.10 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 3 1 1 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 2 x x 3 2 1 Brincliffe Towers Version 1.10 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 78 Regulation 15 Requirement Daily recordings must detail the action taken by staff to ensure that service users identified needs are being met. (Previous timescale 1 November 2004) Medication systems must be regularly monitored so that any discrepancies can be quickly identified and appropriate action taken. Timescale for action 1 June 2005 2. 9 13 3. 9 13 All medication must be signed for at the time of administration. 4. 10 12 All service users must be treated in a manner which respects their privacy and dignity at all times. Staff must be trained/instructed regarding appropriate conduct when speaking to service users. Immediate as instructed on the day of the inspection. 6 April 2005. Immediate as instructed on the day of the inspection. 6 April 2005. Immediate as instructed on the day of the inspection. 6 April 2005.
Page 20 Brincliffe Towers Version 1.10 5. 18 13 6. 19 12 7. 22 23 8. 25 23 All staff must undertake formal training on adult protection procedures. (Previous timescale of 31 March 2005 not met). Curtains or blinds must be provided in all toilets. (Previous timescale of 30 June 2004 not met) Bathrooms and toilets must be refurbished and suitable adaptations installed to assist service users that are old, infirm or physically disabled. (Previous timescale of 30 November 2003 not met) The exposed pipe work in the service users bedroom must be made safe. 1 July 2005 1 June 2005 1 August 2005 9. 33 26 10. 38 13 Visits by the Registered Provider must take place as detailed in Regulation 26 of the Care Homes Regulations, and comprehensive reports must be provided. All staff must undertake fire drills and practices as per the homes policy and procedures. Immediate as instructed on the day of inspection. 6 April 2005. 1 June 2005. 11. 38 13 Confirmation that the fixed electrical systems have been checked/serviced at the required interval must be forwarded to the CSCI Sheffield area office. Immediate as instructed on the day of the inspection. 6 April 2005. 1 June 2005 Brincliffe Towers Version 1.10 Page 21 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. 2. Refer to Standard 28 30 Good Practice Recommendations By 2005 there should be 50 of the care staff trained to NVQ Level 2. Alternative training methods should be sought to offer more indepth guidence in subjects relavent within the caring profession. Brincliffe Towers Version 1.10 Page 22 Commission for Social Care Inspection 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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