Inspection on 19/09/06 for Bryan Wood Care Home ta Southern Cross Healthcare

This inspection was carried out on 19th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

CARE HOMES FOR OLDER PEOPLE Bryan Wood Care Home t/a Southern Cross Healthcare 1 Bryan Road Edgerton Huddersfield West Yorkshire HD2 2AL Lead Inspector Karen Summers Unannounced Inspection 19th September 2006 08:45 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 Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 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. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bryan Wood Care Home t/a Southern Cross Healthcare 1 Bryan Road Edgerton Huddersfield West Yorkshire HD2 2AL 01484 453366 01484 453344 Address 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) www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Mr Colin Grubb Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13th December 2005 Brief Description of the Service: Bryan Wood is situated just off the Halifax Road in the Edgerton area of Huddersfield. It is approximately one and a half miles from the town centre and close to a small shop and a bus route. The home consists of a large house and two purpose built extensions. Inside there are three lounges and a dining room. Outside is an attractive patio with seating for service users and their guests to use during the better weather. While the majority of people at Bryan Wood live there permanently the home also offers some short break accommodation. Fees at the home start at £344.71 - £427 per week. Items not covered by fees include: Newspapers, hairdressing and chiropody. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a key inspection, which included an unannounced site visit on the 9th September 2006, and the duration of the inspection was 7 hours. There were 36 service users in residence on the day. Mr C Grubb, manager, was present throughout the inspection. The following areas were looked at and have been used in the production of this report; a sample of records, care plans, medication, individual discussion with 5 service users, 1 relative, two members of staff, tour of the premises and document reading. To reflect the views of those who use the service, satisfaction questionnaires were sent to: 10 service users, 7 were returned; 10 relatives/ advocate/ friend, 8 were returned, 3 GP’s, 3 were returned, and district nurses, none were returned. The inspector would like to thank those who contributed to the inspection process, and also thank Mr C Grubb, his staff and service users, for their time and hospitality on the day of inspection. What the service does well: What has improved since the last inspection? What they could do better: The ridge in the lounge floor should be investigated and made safe. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 6 The areas of decoration that are showing signs of wear and tear should be redecorated, and any stained, worn carpets should be replaced. Staff should ensure that the daily record reflects the outcome of the planned care and/ or assistance that is given to the service user, and when a service user is re admitted to the home, the self-administration risk assessment should be reviewed/ updated. The activities that the service user is involved in on a daily basis should be recorded. A minimum ratio of 50 trained members of care staff to have achieved an NVQ level 2 or equivalent. 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. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 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 Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 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): 2-5 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. No service user moves into the home without having had his/ her needs assessed and been assured that those needs will be met. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. EVIDENCE: The home offers respite and long term care, and prospective service users and their relatives are encouraged to have a look around the home, and spend some time there before deciding to move in, and service users are admitted following an assessment of their needs. Once satisfied that they can meet the service users needs a letter is sent offering them a place at the home. Without exception, all service user questionnaires stated that they receive enough information about the home before deciding it is the right home for them. One service user said, “We received a folder, and spoke to Colin the Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 9 manager who showed us around, and informed us of all charges, activities etc.” Service users are provided with a statement of terms and conditions at the point of moving into the home, or contract if purchasing their care privately. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users receive the level of support they require to ensure that all aspects of their health and social care needs are maintained. Unless the risk assessment for self-administration of medicines is updated when service users are re admitted to the home, they could potentially be at risk. Service users are treated with respect. EVIDENCE: Care plans were of a good standard and set out the action that needs to be taken by care staff, to ensure that the needs of the service users are met. The care plans also included risk assessments, both of which have been reviewed once a month, or as the needs of the service user has changed. Evidence also indicated that service users are getting the appropriated health care as required. Staff should ensure that the daily record reflects the outcome of the Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 11 planned care and/ or assistance that has been given to the service user, as this was not always evident. Without exception the questionnaires from relatives stated that they were satisfied with the care provided, and the questionnaire returned from doctors also stated, that they were satisfied with the overall care provided, and that staff demonstrate a clear understanding of the care needs of service users. Medication housekeeping was of a satisfactory standard and should a service user wish to self- administer their medication, there is a risk assessment and documentation. A service user who had previously been a resident at the home had been re admitted for respite care. The service users care records had been updated, with the exception of the assessment for self-administration of medication. The medication records should also be reviewed/ updated to show whether there has been a change in the service users needs. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 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 - 15 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Without the documentation relating to the service users social needs been kept up to date, there is no evidence to suggest that the lifestyles experienced in the home matches their expectations and preferences, and satisfies their social, religious, and recreational interests and needs. A variety of meals are offered that take into account the likes and dislikes of the service users and their religious and cultural needs. EVIDENCE: The service user’s social record were filled in on an ad hoc basis, therefore there was no documented evidence as to how the service users individual social, and religious needs were been met, and where the record had been completed the information did not show whether the service user had enjoyed the activity. The service users who were spoken with said that not a lot goes on, and one relatives questionnaire said, “More fitness activities to stimulate would help.” Overall, the service users questionnaires said that there were activities that they could take part in, and one person said that they “could be a little more varied.” There is an activities person who works four days per week, and Mr Grubb, the manager said that he had arranged to have a Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 13 meeting with the staff as to how the activities can be covered when the activities person is not around. There is an activity programme that is published every four weeks and service users are invited to participate in any of the events advertised. The information is distributed to relatives and prospective service users and is also displayed around the home. It is also available in large print, floppy disc or on tape. Activities include; beauty therapy, crafts, bingo, individual activities, going out for a walk, dominos, visits to the garden centre, luncheon clubs, and many more. Every other Tuesday the home also has a luncheon club where service users from the community and Alwoodleigh care home visit Bryan Wood. In addition to the activities programme there is a four weekly newsletter informing service users on matters of interest. Personal newspapers are delivered twice daily on request. The menus offered a variety of food, and individual service users food preferences; specialised diets and cultural needs had also been taken into consideration when planning the menus. Without exception the service users questionnaires said that they always liked the meals. One relative commented that, “Mum seems very happy with her meals, and it is a pleasure to see her eating again. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon in a timely manner. Service users are protected from abuse. EVIDENCE: There is a complaints procedure which specifies how complaints may be made, and with an assurance that they will be responded to within a maximum of 28 days. A complaint had been made in July this year, which was in relation to the breakfast menu and a poor availability of food. A written apology was given. Staff have had abuse awareness training. There is also a whistle blowing procedure, and staff were aware of the procedure to follow. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. A number of areas around the home were showing signs of wear and tear and in need of redecoration. The premises are clean and systems are in place to control the spread of infection. EVIDENCE: At the time of the visit volunteer relatives were laying gravel and planting tubs at the front of the building. Staff were also replenishing the patio area flower beds. Service users are encouraged to bring small items of furniture and memorabilia into the home, and a number of bedrooms had been individualised with Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 16 belongings, and reflected the personalities and tastes of the people living there. The decorative condition of the dining room was showing signs of wear, as the wallpaper was lifting and in need of redecoration. Mr Grubb said that the room is to be redecorated, and a new floor laid and the furniture replaced. Mr Grubb also said that the hall was to be redecorated the next day. Two bedrooms had recently been redecorated. Areas of corridor around the home were showing signs of wear and tear, and should be redecorated, and the lower ground floor corridor carpet was also looking stained, and in need of replacement within the redecoration/ refurbishment programme. The main lower ground lounge leading to the patio area; there was a marked ridge in the floor where two rooms have been joined together. There is a potential risk that someone could trip over the ridge, therefore the area should be investigated and made safe. In the interim period risk assessments should also be done to protect service users. The premises were clean and systems are in place to control the spread of infection. Two service user satisfaction questionnaires commented that the home was always clean, and four said that it is usually clean. The home is generally in a good state of repair and decorative condition, and service users’ individual needs are met in a comfortable and homely way. The premises are clean and systems are in place to control the spread of infection. At the time of the visit volunteer relatives were laying gravel and planting flowerbeds at the front of the building. Staff were also replenishing the patio area flowerbeds. Service users are encouraged to bring small items of furniture and memorabilia into the home, and a number of bedrooms had been individualised with belongings, and reflected the personalities and tastes of the people living there. The home is in the process of having the main hall re painted. The dining room is also to be redecorated, a new floor laid and new dining room furniture has been ordered. Two bedrooms have also recently been redecorated. Areas of corridor around the home were showing signs of wear and tear, and should be redecorated, and the lower ground floor corridor carpet was also looking stained, and in need of replacement within the redecoration programme. The main lower ground lounge leading to the patio area; there was a marked ridge in the floor where two rooms have been joined together. There is a potential risk that someone could trip over the ridge, therefore the area should be investigated and made safe. In the interim period risk assessments should also be done to protect service users. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 17 The premises were clean and systems are in place to control the spread of infection. Two service user satisfaction questionnaires commented that the home was always clean, and four said that it is usually clean. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 18 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 - 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing levels and skill mix were sufficient to meet the number and needs of service users. Service users are supported and protected by the home’s recruitment practices. Staff are also trained and competent to do their job. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of service users in the home. Four out of eight relative’s questionnaires stated that, in their opinion, there aren’t always sufficient numbers of staff on duty. 40 of care staff have achieved an NVQ level 2, or equivalent, 7 have started the course and 4 are near completion. The registered person operates a thorough recruitment process, ensuring the protection of service users. Staff confirmed that they had had induction training within 6 weeks of their employment, and were able to say what the induction included. The information was also recorded in the staff training files. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 19 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): 31,33,35 & 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The service users benefit from the management approach of the home and the registered manager ensures so far as is practicable that the health, safety and welfare of service users and staff are protected. Service users are safeguarded by the accounting and financial procedures of the home. EVIDENCE: The manager has an NVQ 4 in management and the Registered Managers Award. In relation to quality assurance, twice a month Mr Grubb carries out audits of the home which includes: home presentation, medication, care records, Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 20 accidents, finances, training, social activities etc. And in addition to this there has been a survey looking at quality that the home provides, and this has been done by someone not connected to the home. The outcomes of surveys are discussed at residents and relatives meeting, and are also published in a monthly newsletter. Two service users financial records were examined and satisfactory records were been maintained. Satisfactory records are maintained for accident reporting, fire alarms and emergency lighting. There was also evidence to suggest that all staff have had movement and handling training, and fire drills/ lectures. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 OP19 Regulation 13.-(4)(a) Requirement The ridge in the lounge floor should be investigated and made safe. In the interim period risk assessments should be done to minimise the risk. Please confirm in writing by 20/10/06 when this will be addressed. Timescale for action 20/10/06 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. 2. 3. 4. Refer to Standard OP7 OP9 Good Practice Recommendations Staff should ensure that the daily record reflects the outcome of the planned care and/ or assistance that is given to the service user. When a service user is re admitted to the home, the selfadministration risk assessment should be reviewed/ updated. The activities that the service user is involved in on a daily basis should be recorded. The areas of decoration that are showing signs of wear DS0000065973.V297009.R01.S.doc Version 5.2 Page 23 OP12 OP19 Bryan Wood Care Home t/a Southern Cross Healthcare 5. OP28 and tear should be redecorated. Any stained, worn carpets should be replaced. A minimum ratio of 50 trained members of care staff to achieved an NVQ level 2 or equivalent. Bryan Wood Care Home t/a Southern Cross Healthcare DS0000065973.V297009.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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. 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