Inspection on 29/09/05 for Bryher Court Nursing Home

This inspection was carried out on 29th September 2005.

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 27/09/06

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 29th September 2005 13.30 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.V250727.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 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 Mr Paul Kevin David Barron Ms Chiasseriniand 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.V250727.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum service users to be accommodated is (45). Service users should be aged 65 years or over on admission. Date of last inspection 7th June 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 accessible for those with limited mobility and it is arranged over three floors: two internal passenger lifts enable access to all floors. A lounge and large conservatory, which is used as a dining area, provide communal space. There are twenty-one single rooms and six double rooms with en-suite facilities, and twelve rooms with shared facilities. At the front of the building there is a large parking area. Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of almost six hours beginning at 1.30pm. The Inspector met with the Registered Manager and six other staff. The Inspector also undertook a tour of the Home meeting with many of the 36 patients currently living there. There was the opportunity to chat privately with nine patients, a relative and a visitor, before inspecting a range of documentation and key records. This report should be read in conjunction with the report from the last Inspection on 7th June 2005. What the service does well: What has improved since the last inspection? What they could do better: The Terms & Conditions of a patient’s residence at Bryher Court should include the room to be occupied and any additional payment needed for services not included in the fees. All patients should have a Care Plan detailing the care needed to ensure their health, personal and social care needs are met. These should then be reviewed and updated to reflect any change in need. More detailed assessments must be carried out in respect of individual patient’s social and emotional needs. The complaints procedure needs amending to provide contact details for the Commission and to reflect a twenty-eight day time-scale for investigation. CRB disclosures must be applied for, for each prospective employee and a photo and proof of ID for each staff member must be held ‘on Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 Page 6 file’. Formal patient feedback about the services provided should be sought and the results should be publicised. Staff should receive formal supervision at least six times a year. Sessions should include the career development needs of the individual. 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.V250727.R01.S.doc Version 5.0 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.V250727.R01.S.doc Version 5.0 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 and 2 The Terms & Conditions should include the room to be occupied and the additional services to be paid for over and above those included in the fees. EVIDENCE: A detailed Statement Of Purpose and Resident’s Guide are in place, providing information for prospective patients. As identified in the last inspection, the Statement Of Purpose gives information about the staffing levels when the Home is full, but it does not state the number of patients the Home is actually registered to accommodate. The Manager confirmed that the owner currently has the Statement Of Purpose for its amendment. Once an admission to the Home has been agreed, each patient is provided with a copy of the Terms and Conditions. It clearly identifies the services included, although does not specify the room to be occupied and the additional services to be paid for over and above those included in the fees. Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 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 10 Each patient should have a Care Plan detailing the care needed to ensure all aspects of the health, personal and social care needs of the patient are met. These should then be reviewed by the care staff at least once a month and updated to reflect the changing needs of the patient. More detailed assessments must be carried out in respect of individual patient’s social and emotional needs to meet the Requirement from the last two inspections. Health care needs appear to be met well. Patients feel their privacy is upheld. EVIDENCE: Bryher Court provides 24 hour nursing care if required. Three patient files were viewed and the Inspector met with those patients. Each patient has a Long Term assessment, which had been reviewed annually for the files seen. A risk assessment for falls, a nutritional assessment, a dependency assessment and an assessment of tissue viability were evident. However in the files viewed, there were no care plans identifying the patients’ needs and prescribing the health, personal and social care to be implemented. This was discussed during the Inspection: it was confirmed that care plans are being introduced as able. With few care plans in place, limited progress has been made since the last inspection, in documenting assessments of individual patients social and emotional needs. Similarly records also show limited progress in documenting within the daily Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 Page 10 records how the social and emotional needs of patients are being met or any changes in their mental health needs. Pressure mattresses are used when required. The Home enables the patients to have access to the external health professionals they need and staff accompany them to health appointments. Specialist nurses are contacted for specific health needs. Staff are committed to promoting privacy and respect for patients. Preferred terms of address are reflected in the patients’ files and a telephone is provided in each room with the facility to receive and make personal phone calls. Screens are available in each double room to provide privacy. Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 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): 14 and 15 The patients within the Home in general handle their own financial affairs and they are encouraged to personalise their bedrooms. The menus are varied and nutritious and specific dietary requests and needs are accommodated. EVIDENCE: The Home manages the monies for one patient, holding an account in their name, which can be accessed by the Administrator and a relative. Records are kept of any transactions. Patients are encouraged to bring their own possessions into the Home and there was evidence during the Inspection that rooms had been personalised with furnishings and small items of furniture. The Inspector met with the chef and inspected the Home’s food preparation area. Fresh produce including fresh vegetables was evident. There is a 3week menu with a set meal for lunch, but patients can choose an alternative if they prefer. Patients can also choose both a cooked breakfast and a cooked supper and special diets are catered for. A copy of the menu is on each floor. Meals can be taken in the Conservatory or patients can choose to eat in their rooms. All the patients who met with the Inspector praised the food as varied and tasty. Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 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 The complaints procedure should provide contact details for the Commission and should reflect that complaints must be investigated within a twenty-eight day time-scale. This was a Recommendation from the last Inspection. EVIDENCE: A detailed complaint procedure is in place. There have been no complaints received by the Commission, since the last inspection. The complaint procedure in the Home’s policy and procedures manual has not been updated to reflect the contact details for the Commission and the timeframe to work within. The policy on display in the Home has been amended. Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 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, 23 and 24 Bryher Court is well maintained and the environment is comfortable. Patients are encouraged to personalise their rooms by having their own possessions around them. EVIDENCE: Bryher Court provides a well-maintained, comfortable environment with accommodation over three floors. Two passenger lifts enable access to all floors for those with reduced mobility. A lounge on the ground floor, leading through to a large conservatory that is used as a dining area, provides communal space for watching television or meeting with visitors. From the conservatory there is access out into well-maintained grounds with a patio area. The bedrooms are comfortably furnished with lockable storage space and a telephone. Each room has a lockable door and, following a Risk Assessment, some rooms have been fitted with a magnetic door release enabling those patients to have their door open whilst they are in their room. Adjustable beds are used for those patients needing nursing care. There are either en-suites or separate toilet and bathing facilities within easy access of each room. There has recently been a new fire system installed and the emergency lighting inspection was in September 2005. Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 Page 14 Each room and area of the Home has a fire Risk Assessment, last completed on 17th August 2005. The maintenance man tests the emergency lighting monthly and the fire alarm is tested weekly, meeting the Requirement from the last inspection. Fire training was held on 17th February 2005 and a further session was planned for the day following the inspection. Fire drills are held regularly: the last recorded practise was on 5th August 2005. Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 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): 29 and 30 A formal recruitment procedure is in place but CRB disclosures must be applied for, for each prospective employee and a photo of each staff member and proof of their ID must be held ‘on file’. This was a Requirement from the last inspection. Staff receive an induction into the Home and there is some staff training in place: however it does not occur on a regular and frequent basis for all staff. EVIDENCE: Four staff files were viewed. Three of those staff had been employed this year. Their files showed that the Home follows a formal recruitment procedure. All contained references received prior to appointment. CRB disclosures were evident in all files: one disclosure was dated July 2004 but the member of staff’s application was dated January 2005. All files had a copy of the Terms and Conditions of employment. However two files did not contain a photo or other proof of ID. This was a Requirement from the last inspection. New staff undertake an induction programme and records show that training is offered to staff. There is evidence of teaching and clinical updates and staff confirmed that the Home accesses local resources such as health professionals and medical companies for staff training. The last recorded teaching session was in March 2005. Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 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): 31, 33 and 36 The Manager is qualified and competent and manages the Home well. Formal feedback about the services provided should be sought from the patients, their relatives and visitors: the results of that feedback should be published and made available to current and prospective patients and the Commission. 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. EVIDENCE: The Registered Manager is an experienced Registered General Nurse who has worked at Bryher Court for over ten years. She was undertaking NVQ level 4 but has not been continuing with it recently. She is enrolled to start her Registered Manager’s Award (RMA) in February 2006. Both the staff and patients who met with the Inspector, stated that they have confidence in the management of the Home and that they find Matron approachable, helpful and supportive. The views of the patients are actively sought informally and the Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 Page 17 Manager confirmed that the owner of the Home undertakes a monthly visit and audit as required by Regulation 26. The Commission has not received copies of these audits recently. Staff confirmed that they have sessions of supervision: records show these are generally every 1-2 months and that the time is often used for teaching and clinical updates. Not all staff have had regular sessions of supervision. Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 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 2 2 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 x 3 x x x 3 3 x x STAFFING Standard No Score 27 x 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x 3 x x Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 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 OP2 Regulation 5(b)(c) Schedule 4(8) 15 Schedule 3(1)(b) Requirement The Terms & Conditions must specify the room to be occupied and the additional services to be paid for over and above those included in the fees. There must be a Care Plan for each patient which sets out in detail the action which needs to be taken by care staff to ensure all aspects of the health, personal and social care needs of the patient are met. The Care Plans must be reviewed by the care staff at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. More detailed assessments must be carried out in respect of individual patient’s social and emotional needs. (This has been a Requirement of the last two inspections. Timescale given was 31/8/05) Records held in respect of staff recruited to work in the Home must include all the documents listed in Schedule 2. (This was a DS0000013969.V250727.R01.S.doc Timescale for action 31/12/05 2 OP7 31/01/06 3 OP7 15 (2)(b)(c) 31/01/06 4 OP7 16 (2)(m)(n) 31/12/05 5 OP29 19 Schedule 2 30/11/05 Bryher Court Version 5.0 Page 20 6 OP33 24 (1)(a)(b) (2)(3) Requirement of the last inspection. Timescale given was 31/7/05) Formal feedback about the services provided must be sought from the patients, their relatives and visitors. The results of that feedback must be published and made available to current and prospective users, and the Commission. 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The Home should include in their Statement of Purpose, details of the numbers of patients they are registered to accommodate. In addition, they should include reference to staff qualifications and the training opportunities provided to staff in the Home. (This was a Recommendation from the last inspection) Daily notes should make reference to how the social and emotional needs of patients are being met. Records should also show any deterioration in patients’ mental health needs. (This was a Recommendation from the last inspection) The complaint procedure in the policy and procedure manual should be updated, in line with the policy on display in the Home. It should include the contact details for the Commission and reflect the need to investigate the complaint within 28 days. (This was a Recommendation from the last inspection) 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) 2 OP7 3 OP16 4 OP36 Bryher Court DS0000013969.V250727.R01.S.doc Version 5.0 Page 21 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.V250727.R01.S.doc Version 5.0 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!