CARE HOMES FOR OLDER PEOPLE
Bryn Haven Brinnington Road Brinnington Stockport Cheshire SK5 8BS Lead Inspector
Jacqueline Kelly Unannounced Inspection 15th May 2007 9:25 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 Bryn Haven DS0000008544.V339596.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. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bryn Haven Address Brinnington Road Brinnington Stockport Cheshire SK5 8BS 0161-430 2337 0161 430 3770 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) Borough Care Limited Mrs Karen Jones Care Home 42 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (42) of places Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 42 service users to include: *up to 42 service users in the category of OP (Old age not falling within any other category); *up to 7 service users in the category of DE(E) (Dementia over 65 years of age). 6th February 2006 Date of last inspection Brief Description of the Service: Bryn Haven is owned by Borough Care Limited; a not for profit organisation who also manage a number of homes in the Stockport area. The home is registered for up to 42 residents. Bryn Haven was purpose built approximately 45 years ago and is situated on the outskirts of a large housing estate. Over the years, an extension and a conservatory have been added. Apart from one double room, all are single with some having an en-suite toilet with wash hand basin; two bedrooms have a shower in the en-suite. The house has a small garden to the front and a reasonable sized garden to the rear with shrubs, lawns and patio. Off-road parking is available at the side of the house. Ramped access has been provided for those people who may find steps difficult to use. Bryn Haven is close to a direct bus route into Stockport town centre. There is also a train station on the estate, which is direct to Manchester. However, it is approximately a 20-minute walk from the home. The motorway network is within easy reach. The fees range from £339:00 to £398:00. These prices include a £6.00 ‘topup’ charged by Borough Care Ltd for those people who are being funded by a local authority. There is also an additional charge of £12 each week for the ensuite rooms. The home has a statement of purpose and information pack, which includes the service user guide. A copy of the latest inspection report was displayed at the front entrance. The organisation has achieved the Investors in People Award and is a registered charity. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a key inspection which included a site visit. The manager was not told beforehand that the inspection was to take place, this is called an unannounced inspection. Time was spent talking with the manager, Mrs Karen Jones. Residents, relatives and staff were also spoken with; all said that they were happy with the care provided and had no complaints. Care plans, risk assessments, and drug administration records were looked at all of which were satisfactory. Residents’ health and personal care needs were being met. Comment cards from the Commission for Social Care Inspection were sent to three GP’s. At the time of writing this report none had been returned. Forty-two survey forms with free post envelopes were sent to the home for distribution amongst the residents and/or relatives. These had been left on the table in the entrance hall for people to help themselves. On the day of the inspection the table was empty of the forms, however none had been returned to the Commission at this time. The home did not have a specific short stay/respite and emergency admissions service, however when there were empty beds they were used for these services. As the home had a number of empty beds, which was ongoing, these services were being provided regularly. A day care service was also available. On the day of inspection there were four single rooms and one double room empty; a total of six vacancies. The home did not provide intermediate care. A system of split sittings at meal times was in operation; 12pm and 1pm. The people who attended for day care sat on their own table at the first sitting. The manager felt that there was a good senior team working at Bryn Haven who aimed for continual improvement. The Commission for Social Care inspection had received no complaints. One safeguarding adult investigation had been conducted. There had been five complaints received by the home over the past 12 months, all of which had been recorded and dealt with in a satisfactory manner. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 6 What the service does well:
The home is well maintained, with a number of different areas for people to sit and eat. The garden was well stocked with plants and had garden furniture for residents to use during the better weather. The home was clean and free from offensive odours. Residents were encouraged to personalise their bedrooms. The manager carried out an assessment of prospective residents and provided people with information to help them make a positive choice. There was a key worker system in place and, whenever possible, they visited the resident with the manager prior to being offered a place. Care plans were kept in residents’ rooms which gave residents and relatives instant access to information. The home had a stable staff team of care workers, many of whom had worked at the home for a number of years. The inspector received favourable comments from the residents and relatives who were spoken with regarding the staff group. All had a personal profile which, although short, was very informative and gave a picture of the resident’s past life. All the residents who were spoken with said that they enjoyed the food. The inspector was able to see the lunch being served which was well presented and appetising. There was a choice for the majority of meals. There was a menu card placed on each of the dining tables. Daily activities included: daily newspapers, armchair exercises, board games, bingo, darts, sing-along, reminiscence, arts and crafts, social events and visiting the library. Community events: church visits, shopping, parks, pubs and theatre trips, were organised. Aromatherapy massages from a qualified employee of Borough Care were available. Residents’ individual hobbies were catered for. The home encouraged the relatives to take part in the home and organised events aimed specifically for them. The manager said that all the events were well attended. The manager had introduced a ‘Quality Assurance’ file, which was good and was to be used at future meetings to assist the staff to look at ways in which they could improve the service. The staff spoken with were particularly pleased with the training offered by the organisation. Training consisted of dementia care; induction; pressure area care; loss grief and bereavement; first aid; safe guarding adults; medication and moving and handling. National Vocational Qualifications were ongoing. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 7 Staff and resident meetings were held every three months to enable people to express their views and opinions. 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. The summary of this inspection report can be made available in other formats on request. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 8 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 Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3, 6 Quality in this outcome area is good. The assessment process ensured prospective residents’ needs could be met. Sufficient information is provided to help people make a choice. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: All residents, prior to admission (apart from those admitted as an emergency who have a social work assessment only), have a full assessment carried out by the manager of the home and a key worker wherever possible. The manager visited the people either at home or in hospital. Copies of the assessments were kept on the care file. The home did take people through the Rapid Response Team. This emergency service, together with short stay/respite care, was only provided if the home had empty beds. As the home had been carrying vacancies over the past 12 months these services had been provided regularly.
Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 10 Standard 6 did not apply, as the home had no intermediate care beds. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 Quality in this outcome area good. The manager and the staff team met the health and personal care needs of the residents. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: All the residents had a care plan which contained information, including risk assessments, to assist the care workers in providing individual care for the residents. Care plans were reviewed on a regular basis and altered, if necessary, according to the care needs of the residents. The care plans were kept in the residents’ bedroom and were therefore available for residents and relatives to look at should they wish to do so. The services of the GP, District Nurse, opticians and others were obtained as and when necessary. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 12 Medication records were looked at and had been completed correctly. The inspector also observed the deputy manager administering the medication in a satisfactory manner from a lockable cabinet. The inspector spoke with an employee of the pharmacy who was delivering the medication; comments received were positive. All the care workers who gave out medication had received training in safe handling of medicines. The brochure contained statements about the rights of residents to expect their privacy, dignity, independence and choice to be respected. Bryn Haven DS0000008544.V339596.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15 Quality in this outcome area is good. The residents’ daily life and social activities are catered for. The food is good and the residents have a choice. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A varied programme of activities was available for the residents to take part in if they wished to do so. The residents spoken with were happy with what was being provided, both in the home and out in the community. The home also organised functions throughout the year specifically for relatives with residents also being able to attend part of the proceedings. These were well attended. Two relatives were spoken with during the inspection; they were pleased with the care provided. All the people spoken with said that the food was good and there was an automatic choice. Menu cards were placed on each of the dining tables. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16, 18 Quality in this outcome area is good. Residents and relatives were able to express their views and make a complaint should they wish to do so. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home reported that five complaints had been received over the past 12 months; two of which were substantiated. All the complaints had been dealt with in a satisfactory manner and recorded. No further action was necessary. However, it is recommended that the complaints which are included with the compliments be kept separate. This would allow for easier monitoring and inclusion in quality assurance reports. The care audit report, dated 21 August 2006, referred to a safeguarding adults investigation but did not refer to any of the complaints received. A summary of the general complaints recorded should be included in the report with an account of the action taken and what could be learnt to improve the service. The Commission for Social Care Inspection had received no complaints; there had been one safeguarding adult referral. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 15 Residents’ meetings, which took place every three months, gave the residents the opportunity to express their views and opinions. The residents who were spoken with said that they had no complaints. Care workers had received training in safeguarding adults, which was ongoing. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 26 Quality in this outcome area is good. The home is well maintained, clean and free from offensive odours. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home was clean, tidy and maintained to a reasonable standard. A small number of bedrooms were seen during the inspection; all had been personalised. The garden to the rear of the property is a reasonable size and was well kept with plants and a lawn for residents to sit out on. A ramp had been built, which allowed those people in wheelchairs or with walking difficulties easy access. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 17 The home complied with the fire safety regulations and Environmental Health standards. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29, 30 Quality in this outcome area is good. The staff were skilled and trained to meet the needs of the residents. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: There were sufficient staff employed to ensure that the residents’ health and personal care needs were met in a clean and comfortable home. The staff had received training in core skills, such as adult protection, medication administration, moving and handling and health and safety. Many had completed a National Vocational Qualification (NVQ) Level 2 and/or Level 3. A small number of staff files were looked at which contained a record of training received and supervision notes. The application form was discussed with the manager where it was suggested that the ‘employment history’ section be amended to include the statement: ‘from leaving school or full time education and explain any gaps’. All staff had received a Criminal Record Bureau disclosure, however the inspector did not see these as they were kept at head office.
Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 38 Quality in this outcome area is good. The residents were kept safe through procedures and staff training. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A Care Audit report for 2006 had been completed and a copy was given to the inspector. The requirement to write a quality assurance report, which is sent to the Commission and made available to residents, was discussed with the manager. It was agreed that the Care Audit report would fulfil this requirement. However, the report should contain information about complaints (as stated previously) and include the analysis of completed questionnaires.
Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 20 Neither the organisation nor the manager was responsible for any of the residents’ finances. Formal staff supervision and annual appraisal took place on a regular basis and was recorded. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 17 3 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP16 OP29 OP33 Good Practice Recommendations The complaints should be separated from the compliments to enable easy monitoring of complaints. The application form should include a statement asking for more information about employment history. The annual Care Audit report would be suitable as the quality assurance report required by the Commission for Social Care Inspection. This document will require three additions; to include a summary of complaints, analysis of questionnaires and staff qualifications. The report should be sent on each anniversary to the Commission for Social Care Inspection and made available to residents and relatives. Bryn Haven DS0000008544.V339596.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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