Inspection on 13/12/05 for Brinsworth House Residential And Nursing Home

This inspection was carried out on 13th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brinsworth House Residential And... 29/06/07

Brinsworth House Residential And... 19/07/05

Brinsworth House Residential And... 17/01/05

Brinsworth House Residential And... 27/09/04

Brinsworth House Residential And... 22/01/04

Brinsworth House Residential And... 26/09/03

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 Brinsworth House Residential And Nursing Home 72 Staines Road Twickenham Middlesex TW2 5AL Lead Inspector Jon Fry Unannounced Inspection 13th December 2005 10:45 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 Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 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. Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Brinsworth House Residential And Nursing Home Address 72 Staines Road Twickenham Middlesex TW2 5AL 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) 0208 894 1351 0208 894 0093 sheila@eabf.org.uk www.eabf.org.uk Entertainment Artistes` Benevolent Fund Mrs Sheila Gould Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability over 65 years of age of places (36) Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specified male aged 59 years of age until he reaches the age of sixty five years. 19th July 2005 Date of last inspection Brief Description of the Service: Brinsworth House is a care home providing both residential and nursing care for thirty-six residents. The home provides care only to residents with a past and present involvement in the entertainment business or to their dependants. The home is a large detached property set in its own grounds and located close to local facilities and transport. Brinsworth House is owned and operated by The Entertainment Artistes Benevolent Fund (E.A.B.F). Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by a regulation inspector on the 13 December 2005. The inspection took place over six hours. The inspector spoke with fourteen residents, one visitor, the manager and three members of staff. A number of records were examined, as well as a tour of the communal areas of the home. What the service does well: What has improved since the last inspection? What they could do better: The home must make sure that staff keep accurate records for the administration of medication. All medication must be administered as prescribed. There are opportunities to develop the information contained within the care plans for individual residents. Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 Page 6 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. Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 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 the following standard(s): 3 and 4. Resident’s benefit from their needs being appropriately assessed before admission. EVIDENCE: There is an appropriate procedure to make sure that the individual needs of a resident are assessed before they move into the home. These assessments were seen for two residents. Fourteen residents were spoken to during the inspection visit. Comments regarding the care provided at the home were generally very positive and included “I’m very happy”, “about the best you’ll find” and “I have benefited by being here”. Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 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 the following standard(s): 7 and 9. The changing needs of residents are addressed by the home. Care plans are fully completed and reviewed each month. The care plans could be developed to include better information about life history, sexuality and end of life wishes. The systems to make sure that medication is safely administered to residents require minor improvement. EVIDENCE: Care plans were observed to be in place for two residents whose documentation was looked at and these were being reviewed on a monthly basis. The information was up to date and satisfactorily addressed areas such as mobility, personal hygiene and social interests. There is scope to develop the care plans to include better information as required about areas such as sexuality, end of life wishes and life history. One instance was seen where a care plan for ‘expressing sexuality’ said that the resident liked to be ‘smart, clean and well dressed’. It may benefit care Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 Page 10 staff to discuss care planning around sexuality to make sure that good information is recorded as required. It is also recommended that the care plans reflect the person and their life history or experiences. This may provide care staff with valuable information to aid communication with residents. Medication administration records were generally well maintained but further improvement is required to fully ensure the safe administration of medicines to residents. One instance was found where a medication was not being administered as prescribed to one resident. This was due to a mistake in the completion of the administration record in use at the home. Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 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 the following standard(s): 12 and 15. Residents have opportunities to engage in appropriate activities. The dietary needs of residents are well catered for. Residents gave positive comments on the quality of food on offer. EVIDENCE: A full programme of Christmas parties and activities was ongoing at the time of this visit. A Mass was being held for residents with visiting singers on the day of inspection and a large residents and relative’s party had been held in early December 2005. A Carol Service was planned as well as another Christmas party within the next week. Residents spoke very positively about the entertainment on offer. One resident said there were “lots of activities on offer” whilst another person said that the recent Christmas party had been “fabulous”. Residents generally also gave very good feedback on the food provided. Comments included “very good”, “excellent”, “first class” and “beautiful”. Two residents said that they thought the food had improved over recent months whilst one resident said that they were “not satisfied” with the provision. Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18. A satisfactory complaints procedure is supplied to residents on admission to the home. Satisfactory policies and procedures are in place to protect residents from abuse. EVIDENCE: The homes policy and procedure on complaints provides appropriate information to residents on how they can make a complaint. Systems are in place for recording any complaints made. Actions taken and outcomes reached are fully documented within this record. None of the residents spoken to reported any concerns at the time of this inspection visit. Two residents spoke about how they would speak to the manager if they had any problems. One resident said “the matron sorts out complaints”. In order to ensure the protection of residents from abuse staff are provided with training on recognising and dealing with any suspected abuse. The home has a procedure for staff to ensure they are able to respond effectively to any concerns. Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 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 the following standard(s): 19, 20, 24, 25 and 26. Residents at Brinsworth House enjoy a homely and comfortable living environment. The premises are well kept and maintained to a high standard of cleanliness. EVIDENCE: The communal lounge and dining areas provide a very comfortable and wellmaintained living environment for residents. There are two spacious lounges; a conservatory, bar area and a large dedicated dining area. An attractive garden area is also available for residents use. New carpeting had been provided in all communal hallways throughout the home in 2005. The manager additionally reported that new laundry machines had been fitted as planned to update the systems in place. Two bedrooms were seen on the day of inspection with each being personalised to the individual resident. Comments from residents about their bedrooms included “fine”, ‘comfortable’ and “ok”. Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 Page 14 Maintenance work ongoing at the time of the July 2005 inspection visit to fit all hot water outlets with thermostatic mixer valves had been completed. Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 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 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 and 29. The home has sufficient staff on duty to meet the needs of the residents. Residents are protected by the homes recruitment procedures. EVIDENCE: Residents gave very positive comments on the staff. The care staff were described as “wonderful”, “very good”, “excellent” and “very charming”. One resident stated that staff are “so kind to me”. All residents spoken to said that they felt there were enough staff on duty to meet their needs. Three members of staff reported that they felt there were sufficient numbers of staff for each shift. Two staff members said that the staff team “worked well together”. NVQ training for staff continues with ongoing support from local colleges and providers. The manager reported that twelve members of care staff had now achieved this qualification. The home carries out appropriate checks including Criminal Records Bureau (CRB) checks on staff before they start work in the home. This process helps to ensure the protection of residents. Recruitment records examined for two members of care staff were well maintained and included application forms and identity documents. Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 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 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): 36 and 38. A system for individual staff supervision effectively supports staff members in the delivery of quality care. The health and safety of residents is protected by regular checks being carried out within the home. EVIDENCE: Care staff have regular individual supervision sessions with their line manager and full records of these are kept at the home. The frequency of these meetings improved in 2005. Care staff confirmed that they received regular supervision sessions. Staff carry out regular checks on the building, furnishings and equipment to ensure the Health and Safety of residents and visitors to the home. Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 Page 17 Major works have been carried out to put in new water storage tanks and to make sure that all fire doors are fitted with satisfactory smoke seals. Hot water outlets are now all fitted with thermostatic safety valves to restrict temperatures. Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 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. 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 3 X 3 Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 Page 19 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 OP9 Regulation 13 (2) Requirement The Registered Persons must ensure that the administration of all medication to residents by care staff in the home is fully and accurately recorded. All items of medication must be administered as prescribed. (Requirement carried forward previous timescale of 01.09.05 not fully met). Timescale for action 01/02/06 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 OP7 Good Practice Recommendations It is recommended that the systems for care planning be developed to make sure that good quality information is recorded as required about areas such as sexuality, end of life wishes and life history. DS0000026246.V275349.R01.S.doc Version 5.1 Page 20 Brinsworth House Residential And Nursing Home Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Brinsworth House Residential And Nursing Home DS0000026246.V275349.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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