Inspection on 15/08/05 for Bryn Haven

This inspection was carried out on 15th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bryn Haven 15/05/07

Bryn Haven 06/02/06

Bryn Haven 07/12/04

Bryn Haven 03/06/04

Bryn Haven 12/01/04

Bryn Haven 16/07/02

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Bryn Haven Brinnington Road Brinnington Stockport SK5 8BS Lead Inspector Kath Oldham Unannounced 15 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bryn Haven Address Brinnington Road, Brinnington, Stockport, SK5 8BS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161-430-2337 0161-430-3770 Borough Care Limited Ms K Lea CRH - Care Home 42 Category(ies) of DE(E) - Dementia over 65 (4) registration, with number OP - Old Age (42) of places Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include up to 42 OP and up to 4 DE(E). Date of last inspection 7 December 2004 Brief Description of the Service: Borough Care Limited who owns Bryn Haven also owns other homes in the Stockport area. The home is purpose built and is situated in a housing estate in Brinnington, an area of Stockport. Bryn Haven is registered for up to 42 service users. An extension to the care home has meant that all but one bedroom is single. One bedroom is a twin room. Many of the bedrooms have the facility of an en-suite toilet with hand washing facilities. There is an additional charge of £10 each week for these rooms. Two bedrooms have a shower in the en-suite. The house is set in private grounds with shrubs, lawns and patio areas at the rear. Off road parking is available at the side of the house. Ramped access is available to assist in the independent mobilisation of service users. There are lounges on the ground and upper floors. A lounge on the ground floor is designated for service users who smoke. A conservatory is situated at the side of the house where lounge seating is available. A large dining room is situated next to the conservatory. The atmosphere in the home is welcoming. Support services are in place with a choice of GP’s, visiting district nurses and chiropodist. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day in August 2005. The inspector spent time in conversation with service users and some relatives who were visiting the home. Their comments are included in this report. Twenty comment cards were left at the home for service users and relatives or visitors, their comments are also included in this report. A partial inspection of the premises was undertaken, as was the examination of a sample of documents that must be in place in line with regulation. Time on the inspection was spent in conversation with the manager and senior team. What the service does well: Service users are able to and are assisted to make their feelings and views known to staff and take part in the inspection process through conversation. In the main, service users said that the home is comfortable and that the staff at the home are dedicated and pleasant. The atmosphere at the home is welcoming with staff and service users extending that welcome. A number of service users arrange for visitors to receive drinks and take part in conversations. A number of service users who have been at the home for some time have formed friendships with one another and genuinely care about other service users and welcome them into the home. One service user said that she had made many new friends since coming to live at Bryn Haven although she said she didn’t want to come prior to her arrival. Service users said they want to be positive about their lives and the staff at the home promote this through their involvement with them and their general way of doing things. Comment cards and questionnaires are sent out by the home at different stages of a service user’s admission to see if everything is as it should be. Staff said it is a happy home and service users or their relatives let them know how or if the home is meeting the service users’ needs. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: 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. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5 Service users are provided with information to enable them to make a decision as to whether the home can meet their needs. EVIDENCE: A pack is given to all potential service users which includes the service user guide, details of the complaints procedure and a terms and conditions of residency. The manager said that the home gives service users as much information as they can to let them know about the home. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 9 An assessment is undertaken prior to service users coming to the home and usually done by the manager who visits the service users at their own home or where they are staying, which may be in hospital or at another care home. A member of staff who will be the service user’s key worker also, on occasions, accompanies the manager on the assessment. If the service user’s needs can be met by the home and they like the sound of what the home can provide, an introductory visit is arranged. When possible, the manager makes sure she is on duty on the visit so that the prospective service users see someone who they know on their first visit. The manager said when undertaking the assessment she looks at the service user’s needs and abilities, in addition to the current service user group and their needs and aspirations, and also the skills and experience of the staff group. The manager said it is important to get the balance right to ensure that the home is able to meet the needs of the new service user. Service users said they visited the home before making a decision to have a trial period. One service user said she was admitted from hospital and her family looked round for her as she was not well enough. The service user said her family couldn’t have chosen better. One service user said they visited the home to see if it was what they were looking for and whether they liked the feel of the home, and that they had a meal and stayed for as long as they wanted. Another service user said once they had been to look round they knew they liked it. Relatives said their first impression of the home on arrival was positive, they were welcomed and staff were friendly. Examination of a sample of care files identified that there was a contract of residency in place and a terms and conditions of residency provided by the home. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 & 10 Systems are in place to ensure, as far as possible, service users maintain good health. EVIDENCE: All service user files inspected contained a care plan that identified service users’ health, personal and social care needs. Previous inspections have reported the need to develop the recording within the care plans. This development is ongoing and the staff have worked well to record in more detail the specific care need and how these are to be met. The recommendation to continue with this development is detailed in this report. A record is maintained of visits or appointments made to health care professionals, the detail of which can be researched to inform of treatments or plans that are put in place. Service users said they saw the doctor when they were unwell and had every confidence if they needed to attend appointments this would be arranged by staff. One service user said they had to attend a hospital appointment and a member of staff went with them, as they would have been on their own otherwise. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 11 One doctor who was visiting the home commented on how well the home was organised in relation to health care needs and the information that was provided to them on the service users’ presenting health problems. Examination of the medication records identified that medication was recorded as being administered as prescribed by the doctor. A service user said they had their tablets routinely. Another said some of her medication was given to her when she needed it and staff ask her each day if she has any pain and if she had, she has some tablets. Some service users look after their own medication. A risk assessment was in place for this. The risk assessment was not dated or signed so it was not possible to check when this was undertaken and how often this arrangement is reviewed. Medication is administered by staff who have completed basic training in the handling and administration of medication. This has been updated in recent months. Staff in conversation stated how they promote service users’ privacy and dignity when carrying out personal care and when speaking about personal matters. Staff practice was observed on the inspection and time was taken discreetly by staff when undertaking personal care tasks. One relative said their mother had never been so well looked after and they had peace of mind that she was well cared for. All service users’ bedrooms are single with the exception of one double room, which was vacant. Seventeen of the bedrooms have en-suite toilets with two having showers in the en-suite. One service user said she liked to have her own toilet. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 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 standard(s) 12, 13 & 15 Activities, stimulation and menus are determined with input from service users and visitors and families. Service users have a flexible lifestyle in the home and maintain contact with their families and friends. EVIDENCE: One service user said she gets up when she wants and staff call in to see if she is alright and needs any help. The service user said she sees how she is then asks staff to do things that she can’t do for herself. One service user said the “staff are so good and kind” and are “little angels”. Service users said they have their own routines and the home’s routines which suit them. Some service users go out regularly to the shops or to church services; others go out with relatives or friends to their homes for meals or on shopping trips. There are organised activities within the home with entertainers visiting routinely. Service users inform the home which entertainers they like and who they do not. Some service users said there wasn’t enough to do and there should be more visits out for a couple of hours and more regular exercise, as they spend a lot of time sitting. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 13 Relatives said they visit the home when they want and come at differing times to suit their own lifestyle. One relative said they are always made to feel welcome by the staff and by other service users who they have got to know from their visits. Menus are in place on the tables, which act as a reminder of the meal to be served. Service users are asked to make a choice from the menu; their individual likes and preferences are noted and alternatives are provided. Service users said the meals were good and there was always plenty to eat. One service user said she had never eaten so well and that eating in company helps with the enjoyment of the meal. One service user said the “cooks are brilliant” and “they make some beautiful food” and “cakes are their speciality”. A couple of service users took part in a baking class and made cakes. A mealtime was shared with service users. The meal was hot and attractively presented. Staff assistance to service users at the mealtime was supportive and their practice was sensitive to the service users’ individual needs and abilities. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 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 standard(s) 16 & 18 Procedures in the way that complaints are managed ensure that they are dealt with effectively. Some staff did not have training to protect service users from abuse. EVIDENCE: A complaints procedure is in place and those service users spoken to were aware of how they would complain and who to complain to. Most service users said they had no complaints and were happy with the care they receive. A record of complaints and compliments are kept at the home and any complaint, whatever the nature, is investigated and the outcomes discussed with the staff group to assist in the development of the service provided at the home. Adult protection training is scheduled to take place in forthcoming weeks to inform staff what constitutes abuse and to ensure staff are familiar with the actions to be taken if they suspect abuse. A whistle blowing procedure is in place and staff were aware of what they would do if any practice or routine is not of an acceptable standard. One staff member said if she thought things were not right she would not hesitate to alert someone. Some staff have previously had adult protection training and in the future staff induction will include this training. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 23, 24 & 26 Bryn Haven is a safe and generally well maintained home. The home provides a comfortable environment and is clean and tidy. Service users’ bedrooms are personalised and comfortable. EVIDENCE: The home was clean and tidy throughout, with service users’ bedrooms being individualised to suit themselves and their lifestyles. A number of service users were complimentary about their bedrooms, with comments like “they are homely” and that the room has got everything in it that they need, and “the room is lovely”. The upstairs dining room has been redecorated and service users commented on the room needing some curtains at the windows to make it more private. The manager said the curtains had arrived and were to be put up. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 16 Service users said they enjoyed spending time in the garden and commented on the recent fun day held at the home. A ramp is available to gain access to the gardens. Handrails are fitted in order to make it easy for service users to move around the home and outside. Contractors carry out maintenance to the care home’s equipment. Toilets or combined toilets and bathrooms are situated close to lounges and service users’ bedrooms. Infection control procedures are in place at the care home. Inspection of the premises identified that the care home was free from any odours. The care home was clean throughout. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 The procedures for the recruitment and training of staff provide safeguards to offer protection to service users living at the home. The deployment and number of staff on duty is sufficient to meet the needs of service users. EVIDENCE: Staff spoken to said that staffing levels were satisfactory and there was little use of agency staff. The agency, when contacted, is asked to provide staff who are known to the home. Service users said that staff they knew provided care to them and knew what they needed. Staff duty rotas showed that there were five staff on duty in the morning with four staff on for the remainder of the day. In addition, there is also a care supervisor on duty throughout the day. Staff have received mandatory training in topics such as moving and handling, food hygiene and fire procedures. A system is in place to record the training received by staff which ensures that health and safety updates are delivered at the appropriate time. A large number of staff have been successful in obtaining NVQ level 2 and some staff are studying towards NVQ level 3 qualifications. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 18 All staff after interview and the receipt of references attend induction training, Criminal Record Bureau checks are undertaken. Examination of a sample of staff files identified that they all contained all the records and information required to ensure that the staff members were fit to work in the home. There are service user meetings arranged, the most recent being in April 2005. One service user and relative recalled receiving questionnaires seeking their opinions about the home. Relatives said the home often provides opportunities to give feedback. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 & 38 Practices within the home ensure that the health and safety of service users and staff are promoted and protected. EVIDENCE: A selection of records relating to money held by Bryn Haven on behalf of service users was examined. These presented as being maintained appropriately to protect the interests of service users. One relative said she comes to the home periodically to pay in monies for her cared for service user and is given a receipt on each occasion. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 20 Records were seen which indicated that fire protection and detection equipment was checked and serviced at appropriate intervals. Staff spoken to were aware of what to do in the event of fire and confirmed they had received fire drill training and practice. Accident records were completed correctly and audited monthly. Maintenance records viewed were up to date. Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x 3 x x 3 Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 22 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 OP18 Regulation 13(5) Requirement The registered person must arrange for all staff to attend abuse training by external facilitators to ensure their understanding of what constitutes abuse and as an additional safeguard for service users. (Previous timescale of 31/03/05 not met). Timescale for action 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The registered person should continue the development of the care plan to further detail action needed by staff to ensure that all aspects of the health, personal and social care needs of the service user are met. Ensure daily records provide information on the care and interventions provided to service users. The registered person should arrange for all risk assessments to be dated and signed and clearly identify the regularity of the review of the risk assessment. 2. OP9 Bryn Haven F54 F04 bryn haven U s8544 v233686 150805 stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 2nd Floor Heritage Wharf Portland Place Ashton under Lyne, OL7 0QD 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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