Inspection on 27/09/06 for Bryher Court Nursing Home

This inspection was carried out on 27th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Bryher Court Nursing Home 04/02/09

Bryher Court Nursing Home 11/02/08

Bryher Court Nursing Home 29/09/05

Bryher Court Nursing Home 07/06/05

Bryher Court Nursing Home 08/11/04

Bryher Court Nursing Home 22/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

Thorndene

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Bryher Court 85 Filsham Road St Leonards On Sea East Sussex TN38 0PE Lead Inspector Liz Daniels Unannounced Inspection 11:30 27 September 2006 th 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 Bryher Court DS0000013969.V291837.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. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bryher Court Address 85 Filsham Road St Leonards On Sea East Sussex TN38 0PE 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) 01424-444400 01424-440011 Barron Kirk Quality Care Limited Mrs Christine Boniface Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability (45) of places Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum service users to be accommodated is forty-five (45). Service users must be older people aged sixty-five (65) years or over on admission. Service users with a physical disability may be accommodated. Date of last inspection 29th September 2005 Brief Description of the Service: Bryher Court is a large detached building, set in its own grounds in a residential area of St. Leonards-on-Sea. The Home provides nursing and personal care for up to 45 patients of an older age. Administrative, catering, cleaning and maintenance staff support registered nurses and care staff, in fulfilling the patients’ needs. The accommodation is arranged over three floors: two internal passenger lifts enable access to all parts of the building and all areas are therefore accessible for those with limited mobility. There are hoists and bath hoists as well as grab rails and disability aids in the bathrooms and toilets. A lounge and large conservatory, which is used as a dining area, provide communal space and a large garden area to the rear also provides a relaxation area in the warmer weather. There are thirty-five single rooms, twenty-three of which have en-suite facilities, and four double rooms all with en-suite. At the front of the building there is a large parking area for approximately ten cars. The home welcomes prospective residents or their representatives to view the premises, discuss their needs with the Registered Manager and spend time with the staff and residents. Weekly fees range from £500 - £660 as at 8/05/06, for full nursing care. The fees do not include hairdressing, chiropody and any sundries, such as newspapers, toiletries or taxis: these are charged as extras. Information about the service is available from the home’s Manager. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced. It included a visit to the home by an Inspector, which began at 11.30am and lasted for just under eight hours. Two Sisters facilitated the visit as the Manager was away. It also provided the opportunity to talk with them, two other members of staff and one of the catering staff before spending time with several of the residents. No visitors were available to meet with the Inspector during the visit. The Inspector also toured the premises and examined records that included resident’s files, medication records, staff files, and the accident log. Evidence contributing to this inspection has also been gathered from previous inspections, surveys circulated to residents and their relatives (ten of which had been returned to the Inspector) and from data provided by the Registered Manager of Bryher Court. All of the key standards, together with those where concerns had been raised at the last inspection, were inspected. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose still needs further amendment to confirm the qualifications and training opportunities for all the staff: formalising a training programme to include mandatory training, training in adult abuse and specialist training for all staff, will ensure that residents are in safe hands at all times. An improvement in the recruitment procedures for staff and the information held on file will ensure that residents are protected. There must be a protocol in place to meet the National Institute for Clinical Excellence (NICE) guidelines for pressure area care and the home’s quality assurance processes need further development to ensure that the views of service users are instrumental in the development of the service the home provides. The Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 6 Manager must undertake further training to ensure she has the qualifications required for her role. 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. Bryher Court DS0000013969.V291837.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 Bryher Court DS0000013969.V291837.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): 1, 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good information about the service provided at Bryher Court has been produced, and the assessment that takes place ensures resident’s individual needs can be met. EVIDENCE: At the last inspection the Statement of Purpose did not confirm the number of residents Bryher Court is registered to accommodate, or the qualifications and training available for the staff. It has been amended to better reflect the service provided and the qualifications of the trained nurses although does not confirm the qualifications of the care staff or the training opportunities for the qualified nursing staff and care staff. Similarly the Resident’s Guide has been amended and the Administrator confirmed that a copy of the revised information is part of the ‘Welcome Pack’ that is sent out to enquirers and given to any prospective residents who look around the home. A copy of the Commission for Social Care Inspection (CSCI) report is not included but is available from the home’s Manager on request. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 9 Past inspections have found it is usual practice that, following an enquiry, prospective residents or their relatives are invited to visit Bryher Court if at all possible, to spend time with the Manager and staff, view available rooms and discuss the home’s suitability. If it is then appropriate to pursue an admission, the Manager undertakes an assessment in the person’s own home or if they are in hospital, she visits them there. Past inspections have found that details from the assessment are documented. However in the absence of the Manager during this site visit, information from the pre-admission assessments could not be found for the residents whose files were viewed. If the home is suitable and once funding has been agreed (if it is needed), prospective residents are then admitted for a trial period. The resident is then provided with a contract that now identifies the room they occupy, the fees payable and the services provided. One resident who met with the Inspector could recall her family coming to view the home whilst she was in hospital although could not remember a member of staff visiting her there. Similarly another resident explained her daughter looked round to choose the room but she was unaware that she may have had an assessment prior to her admission. All of the ten surveys returned prior to the inspection stated that they had received a contract and also that they had received enough information prior to moving in to enable them to make an informed choice about the home. The care files for three residents were viewed during the inspection. All had evidence of assessment when admitted and the information gathered had been used to underpin their plan of care. Each of the three residents had also had physical and social assessments, as well as various Risk Assessments. Bryher Court does not provide ‘Intermediate Care’ although residents are admitted for planned respite care. Emergency respite care is not provided except in exceptional circumstances. Bryher Court DS0000013969.V291837.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care plans that are updated promote individualised care for the residents and the practises in place encourage residents to be cared for with respect and dignity. The recording of medication administration must improve to ensure residents are protected. EVIDENCE: Three resident’s files were reviewed. All had individualised care plans and risk assessments that had been reviewed and there was evidence that they had been updated. Each day, the staff also complete a daily record for each resident, documenting care provided and any significant events. This has improved since the last inspection as it includes social needs and changes in mood or mental health needs. Any changes in care are also passed on verbally in the handover between each shift. One of the Sisters who met with the Inspector confirmed that the staff discuss the care that is required, with residents and their relatives, on admission. Any Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 11 care given is explained and any new care that is introduced is discussed with them and/or their relative. The condition of residents’ skin is assessed and monitored, any pressure areas are recorded and if a sore develops the treatment and outcome is documented. The Sister confirmed that in general, staff within the home manage any wounds although advice has occasionally been sought from a nurse specialising in tissue viability. However there is no protocol in place to meet the National Institute for Clinical Excellence (NICE) guidelines for pressure area care. These recommend that any person who develops a Grade 2 pressure sore is referred to a nurse specialist, enabling the resident to have expert advice and an individualised plan of treatment. There are various types of pressure relieving mattresses and cushions, to support the management of pressure areas at Bryher Court. Resident’s dependency is also assessed and the risk of falling is identified. The home has electric hoists and hoist-assisted baths for those with reduced mobility. Grab rails are fitted in the toilets and raised seats are available; there are also adjustable beds. Residents have a nutritional assessment and their weights are monitored. The chiropodist visits the home and arrangements are made for residents to see a dentist or optician as needed. Where possible residents remain registered with their own GP or they register with a GP of their choice. No current residents wish to self-medicate. The Sister who met with the Inspector confirmed that a resident’s medication is discussed at their assessment and if the resident then asks to self medicate the Manager assesses whether it is appropriate and records it as a Risk Assessment. The medications for the remainder of the residents are stored in a clinical room, with some stock in a wall cupboard, but most in one of two trolleys. The Medication Administration Records (MAR charts) were reviewed at this visit. Some residents on medication to stabilise their heart rate had not had their pulse recorded prior to the dose. All of the charts had been signed appropriately. The home uses a multi dose system with blister packs. Three tablets had not been given although they had been signed for on the MAR chart. The trained nurses at the home administer medications; they have all had in-house training. Carers assist in the administration of medication although they are not involved in the administration of Controlled Drugs (CDs). A clinical disposal company undertakes the disposal of medications. Medication that is identified as ready for disposal is put into the disposal bin. A record is held although not signed by staff. A pharmacist had audited the medications in the home two weeks previously. Staff who met with the Inspector confirmed that the ethos of the Home is to support residents in caring for themselves as far as they are able but also to provide privacy and show respect when residents are undergoing examinations Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 12 or personal care. During the inspection, staff were observed to be attentive and courteous to the residents. One resident who met with the Inspector commented that ‘staff can’t do enough for me’ and another confirmed that ‘everybody’s nice’. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 13 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, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The pastimes and activities that are available support the residents to experience a lifestyle that matches their expectations and preferences. They also benefit from varied and nutritious meals. EVIDENCE: A large lounge and conservatory on the ground floor at Bryher Court enables residents to sit together and watch television, read or meet with their visitors. Videos, books and games are available and there is an occupational therapy session organised twice weekly. There is also a weekly service and a piano player visits most weeks. Other events are organised for special occasions. Residents and their relatives are told verbally about the activities and special events are publicised in written format. Of the ten service user surveys returned to the Inspector prior to the visit, two said there are ‘always’ activities for them to take part in, four said ‘usually’ and four said ‘sometimes’. Friends and relatives can visit anytime that the resident wishes and staff rearrange meals for any resident who wishes to go out. Residents can meet with their visitors in one of the communal spaces, if they prefer not to meet with them in their own room. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 14 Where possible residents are encouraged to maintain links with the local community. Hobbies, likes and dislikes are recorded in the resident’s initial assessment although not reflected in their care plans. However the Inspector found that the staff she met were aware of the individual likes and interests of the residents and that they support them to continue with them. One resident who spoke with the Inspector enjoys knitting and said how pleased she was that she could continue to do so as the staff help her with ensuring she has the necessary wool; she knits squares which the staff then help her make into different items. The home currently celebrates the Christian festivals and there is a weekly service at the home: arrangements are also made if residents wish to receive Communion. There are currently no residents from an alternative cultural background but some of the staff at Bryher Court are employed from overseas. Although there have not been celebrations for other festivals one of the Sisters who met with the Inspector confirmed that the staff and residents share stories about their own homes and different cultural backgrounds. The staff are therefore confident that the home could meet the needs of residents with varying social and cultural needs. Eight of the residents manage their own financial affairs and for the remainder a relative or solicitor acts on their behalf. The home does not currently act as the appointee for any resident. Residents are encouraged to bring in personal possessions with them. Whilst walking around the home the Inspector met with several of the residents in their bedrooms. Those who spoke with the Inspector said they liked their rooms and had chosen some of their own furniture and belongings to bring with them to make them feel more homely. Staff were seen to be respecting residents’ privacy by knocking before entering. Previous inspections have found the food provided at Bryher Court is varied and enjoyed by the residents. Meals can be eaten in the conservatory or alternatively some residents prefer to eat in their own rooms. The menu seen by the Inspector was nutritious and varied. There is one meal choice on the menu for lunch. However a list of alternative foods that are always available is also publicised. There is a cooked tea, including soup, followed by a dessert. Three residents who met with the Inspector described the food as ‘very good’ whilst in the surveys returned, two people responded that they ‘always’ like the food, and eight said ‘usually’. The kitchen and storage area was viewed. Fresh fruit and vegetables were evident and overall the food was appropriately stored in the fridges and freezers. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a satisfactory complaints procedure and residents are confident that their views are listened to and acted upon. Safe guidance is in place to protect residents from abuse although staff should have formal training in adult protection. EVIDENCE: The Sisters who met with the Inspector were unaware whether there is a ‘Complaints Log’ detailing any complaints or concerns that have been raised with the home, and the investigation undertaken. Previous inspections have found that although there is a complaints procedure in place, which is publicised in the Residents Guide, it does not give details of the timeframes that the complainant can expect the home to work within. Residents seen during this site visit unanimously expressed confidence in the Manager, who they refer to as ‘Matron’ and confirmed that they can raise anything with her. They also said they know she listens and feel reassured that she will follow through their concerns. One stated, “she will follow things through and sort them out”. Of the ten surveys received by the Inspector, nine identified that they ‘always’ know who to speak to if not happy, and one that they ‘usually’ do. One commented, “Matron is available at all times”. Of the ten, six also said they ‘always’ know how to make a complaint and four said ‘usually’. The Commission (CSCI) has not received any complaints about the service since the last inspection. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 16 Past inspections have found that Adult Protection policies and procedures are in place. During this inspection the staff who met with the Inspector demonstrated an awareness of the action to take if they have any concerns about a resident’s welfare as well as where to access the multi-agency guidelines. However they had not had any formal training in the protection of vulnerable adults. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is good. This judgement has been made using evidence including a visit to the service. Bryher Court provides a spacious, comfortable and pleasing environment that is clean and satisfactorily maintained whereby it provides a safe home for residents and meets their individual needs. EVIDENCE: Bryher Court is situated in a residential part of St Leonards on Sea. It is a large detached property that provides accommodation and facilities over four floors, all of which can be accessed by stairs or a lift. There is a good size lounge on the ground floor, which leads into the conservatory overlooking the garden. The garden can be accessed from the conservatory. Radiator guards are in place throughout the Home and windows are restricted. The fire alarm is serviced annually, last in May 2006 and tested weekly. Records show that the alarms had been activated monthly to enable a fire drill for staff on duty, although the last record of this was in February 2006. Different parts of the building are checked to ensure the alarm sounds and the Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 18 fire doors close. There has also been fire training twice this year. All attendances are recorded and the Sisters who spoke with the Inspector confirmed that the Manager monitors that all staff attend the required number of drills each year. There is a fire risk assessment for the home that is reviewed annually: it was last revised in August 2005. As with past inspections the home was found to be comfortably furnished, clean and free from any odours. Five of the respondents in the service user survey answered that the home is ‘always’ fresh and clean, four said ‘usually’ and one responded ‘sometimes’. Policies are in place for managing infected linen and it is washed separately to other laundry. The laundry room is situated on the lower ground floor and infected or soiled linen is not carried through areas where food is prepared or stored. The room has a tiled impermeable floor and washable walls. There are two industrial size washing machines with a 95°C wash and two dryers. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using evidence including a visit to the service. The recruitment procedures for staff and the information held on file needs improve to ensure residents are protected. All staff must have their mandatory training as well as specialist training to ensure that residents are in safe hands at all times. EVIDENCE: Four registered nurses are on duty at Bryher Court during the day, two in the evening and two at night. Five carers support them in the morning, three in the afternoon and evening and three at night. The Manager works some shifts as the nurse in charge and some shifts as an extra, enabling her to provide staff support and to complete administrative work. These numbers appear adequate for the number of residents that the home is registered for. However feedback from the staff and residents who met with the Inspector was that the staff are very busy and there are not always enough staff on duty to spend time with the residents. Agency staff are very rarely used as the home has developed its own ‘bank’ of staff; no agency have been employed within the last two months. Catering and cleaning staff, maintenance and gardening staff are also employed. In the questionnaire completed prior to the site visit the Manager confirmed that twelve of the twenty-four care staff, have or are currently studying for the National Vocational Qualification (NVQ) level 2. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 20 Four staff files were inspected during the visit. Evidence that Criminal Record Bureau (CRB) Disclosures had been received for three of the four staff was found on file. The fourth member of staff had been at the home for over ten years. Two references and a completed application form containing all the appropriate information were in each file. All files also contained a photo and copy of the contract with terms and conditions of employment. No evidence of copies of birth certificates and passports was seen. Staff training is in place for both the trained nurses and the care staff. Past inspections have found that all new staff have induction training and that staff are then supported in their development in their role through mentorship by more senior staff. The staff who met with the Inspector confirmed that the mandatory training, including fire training, ‘Moving and Handling’ and ‘First Aid’, are scheduled on an ad-hoc basis rather than planned for the year, and details of any specialist training that is being arranged locally or national study days are publicised. No matrix or summary of training for each staff member was available to determine whether staff have had their mandatory training within the last year. Two members of staff that met with the Inspector confirmed they were due to have their Moving & Handling training but had had fire training. All training is held in work time whereby staff have a minimum of three paid training days per year. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 21 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, 36 and 38 Quality in this outcome area is good. This judgement has been made using evidence including a visit to the service. The home is well managed in general. However the Registered Manager’s lack of appropriate qualifications does not ensure the residents or their relatives can have confidence that the home is run by a fit person. Quality assurance processes need further development to ensure that the Home is run in the best interests of residents. EVIDENCE: The Manager at Bryher Court is a registered nurse who has been at the home for over thirteen years and has considerable experience in caring for older people. Although commencing the Registered Managers Award (RMA) earlier this year she is currently no longer studying for it. Supported by a Deputy Manager she leads a team of ancillary and care staff. Those staff and residents who met with the Inspector expressed confidence in the management team. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 22 One resident commented that ‘Matron is good’ and a member of staff commented ‘we’re a small stable team and so can discuss things together. We can raise anything – things usually get followed up’. Bryher Court has recently undertaken a survey as part of its quality assurance, to ascertain the views of the residents and their relatives. Although the responses have been received, the survey has not been formally analysed nor the results made available for current and prospective residents. The views of stakeholders in the community are not actively sought although the Sisters that met with the Inspector confirmed that the staff at the home aim to meet with any person who has comments or concerns about the service provided, to enable open discussion. The importance of publicising resident’s feedback for other prospective users of the service was discussed. Internal audits are undertaken and the owner undertakes a monthly, unannounced visit to inspect the premises and speak with residents and staff. Records of these visits were unavailable to view on the day of the visit and no record has been sent to the CSCI. Either the residents at the home manage their own financial affairs or relatives or solicitors act on their behalf. As stated earlier in the report, the home does not act as the appointee for the financial affairs of any of the residents. Residents or relatives pay for services not included in the fees, either as cash on a monthly basis or as part of their monthly bill. The fees and any sundry items or services are separated out on the invoice. Individual resident’s records for sundries bought were not examined on this occasion but past inspections have found them to be well maintained and the relevant receipts available. A recommendation from the last inspection was that the care staff should have formal supervision at least six times a year as identified in the National Minimum Care Standards. This would provide them with the opportunity to discuss all aspects of practice, the philosophy and care in the home and the career development needs of the individual. This was discussed with the staff who met with the Inspector. There is still no formal process whereby staff have individual arranged time with the Manager, her deputy or a senior member of staff. However staff felt that the handover provides a good opportunity for group discussions and concerns about residents, their care or the service provided, although they agreed there was little opportunity to discuss their own training and individual needs. Prior to the site visit the Manager returned data to be considered as part of the inspection. The training information included within that, shows that there has been ‘Moving and Handling’ and fire training as well as some specialist training within the last twelve months. However there appears to be no future training planned. The Sisters that met with the Inspector confirmed that they are not aware of a planned training programme for the year. The information returned prior to the inspection demonstrates that the home is well maintained and this Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 23 was borne out on the day of the inspection. Three monthly water checks to check the water temperature were viewed and fire records were examined. The Accident Log for the home was viewed: slips, trips and falls have been recorded and appropriate action taken. There was no evidence as to whether the Manager monitors all the accidents and therefore identifies if there are any trends and the action needed to reduce that trend. Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 24 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 25 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 OP8 Regulation 13 (1) Requirement Timescale for action 30/11/06 2. 3. OP9 OP16 4. 5. OP18 OP29 6. 7. OP31 OP33 A protocol, that meets the NICE guidelines by ensuring residents are referred to a tissue viability Schedule 3 (3)(n) nurse specialist if they develop a Stage 2 pressure sore, must be in place. 17(1)(a) If medication is not administered Schedule the reason why not must be 3(3)(i) recorded on the MAR chart. 22 (1-6) The complaint procedure that is publicised for residents and their relatives must include details of Schedule 4 (11) the timeframes the home works within. A record of all complaints received and the action taken must be held. 13(6) Staff must be trained in the recognition and management of Adult Abuse 19 A copy of their birth certificate Schedule and passport must be held on 2 file, for all staff that work in the Home. (This was part of a Requirement of the last inspection). 9(1)(2)(b) The Manager must continue to (i) undertake the Registered Managers Award (RMA) 24(1)(a)( The results of formal feedback DS0000013969.V291837.R01.S.doc 27/09/06 30/11/06 31/03/07 30/11/06 31/12/06 31/12/06 Page 26 Bryher Court Version 5.2 b) (2)(3) 8. OP36 18(2) from the residents, their relatives and stakeholders, about the services provided by the home, must be published and made available to current and prospective users, and the Commission. Care staff should receive formal 31/12/06 supervision at least six times a year. The sessions should cover all aspects of practice, the philosophy and care in the Home and the career development needs of the individual. (This was a Recommendation from the last inspection) 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. 4. Refer to Standard OP9 OP19 OP36 Good Practice Recommendations Medication ready for disposal should be signed and checked by two nurses The fire risk assessment for the home should be reviewed annually – (last reviewed in August 2005). Staff should receive formal supervision at least six times a year. The sessions should cover all aspects of practice, the philosophy and care in the Home and the career development needs of the individual. (This was a Recommendation from the last inspection) Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Bryher Court DS0000013969.V291837.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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