Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 16/02/06 for Little Brocklesby House

Also see our care home review for Little Brocklesby House for more information

This inspection was carried out on 16th February 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a comfortable, safe and homely environment for people to live in. It is very well managed and organised. Residents have comprehensive care plans, and are fully consulted about things that affect their lives. The management team gain peoples views on the service by having regular residents meetings and holding care reviews. Staff are well trained and supported by the registered manager and have a sound knowledge of residents needs.

What has improved since the last inspection?

The home has made progress in improving its care records both in terms of quality and the method in which they are filed. Door guards have been fitted to some doors in the care home. A review of security is being carried out and appropriate window locks fitted throughout the home. A rolling programme has been established to replace the thematic valves on the hot water systems for the home.

What the care home could do better:

The company has reviewed its method of recording the initial assessments. The document being used at the time of the last inspection and the present inspection does not itemise sufficiently the assessment needs of residents. When needs are identified the management of that need and resources required must be identified. The management agreed to review the method in which assessments are recorded to ensure the standard is met. It should be recognised that this has not been a problem at past inspections until the new form was introduced.

CARE HOMES FOR OLDER PEOPLE Little Brocklesby House High Street Great Limber Lincolnshire DN37 8JL Lead Inspector Mr Ken Hague Unannounced Inspection 16th February 2006 09:00 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 Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 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. Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Little Brocklesby House Address High Street Great Limber Lincolnshire DN37 8JL 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) 01469 561353 01469 561353 Little Brocklesby House Ltd. Mrs Sheila Casey-Evans Care Home 36 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (31) of places Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide are for service users of both sexes whose primary needs fall within the following categories Old Age not falling into any other category - OP (31) Dementia - Over 65 years of age - DE(E) (5) The maximum number of service users to be accommodated is 36. 30/11/05 2. Date of last inspection Brief Description of the Service: Little Brocklesby House is a two storey care home located in the village of Great Limber, which has a pub and a post office/general store. It is situated ten miles from Grimsby . The home is located down a private driveway, away from the main road and is set in nine acres of parkland on the edge of the Lincolnshire Wolds. It was built during the mid Victorian period and has retained many original period features internally which help make it homely. Bedrooms are located on both floors; the upper floor is accessed by a sweeping staircase or passenger lift. The home provides care for residents over the age of 65 years and can accommodate up to 5 residents who have dementia. Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 8am and 12.30pm. The main method of inspection used is called case tracking which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. A tour of the premises was conducted and care records were inspected. One member of staff and four service users were interviewed. The registered manager and deputy manager were involved in the inspection. What the service does well: What has improved since the last inspection? What they could do better: The company has reviewed its method of recording the initial assessments. The document being used at the time of the last inspection and the present inspection does not itemise sufficiently the assessment needs of residents. When needs are identified the management of that need and resources required must be identified. The management agreed to review the method in which assessments are recorded to ensure the standard is met. It should be recognised that this has not been a problem at past inspections until the new form was introduced. Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 6 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. Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 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 Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 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 Written information is available for new residents and their relatives to advise them what services and facilities are available in the home with residents being clear about what services they are paying for. Residents’ are only admitted if the manager and senior staff are sure that their needs can be met. The assessment records do need to be improved to ensure that all needs are identified. EVIDENCE: The home has a statement of purpose and service users guide which sets out the resources and facilities offered by the home. This is provided to all new residents. The care files of residents being case tracked contain details of the terms and conditions for their stay at the care home. These were signed and dated by residents. The home reviewed its assessment process in 2005 and introduced a new format for recorded information. This unfortunately did not record as much detail as the forms used prior to 2005. This has resulted in the lack of detailed information in relation to how residents assess needs are to be met. Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 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): 7,8,9 & 10 Care plans did not identify all areas of need or provide detailed care instructions for staff to enable them to provide appropriate care. Residents’ health needs were being met. The medication policy of the home is being followed. EVIDENCE: Each resident has an individual plan, which contains information relating to his or her care needs which are reviewed on a monthly basis. Care Plans do however need to provide more detail. One resident’s care records described the frequency of bathing but gave no details of the equipment required, the number of staff required to provide care and the choices and wishes of the resident. Residents’ health needs were being met. Visits by doctors, chiropodists, dieticians and physiotherapists were recorded on their files. The home has a medication policy which meets the National Minimum Standards. The discussion with staff checking of medical records confirmed that this policy was being followed by staff at the home. The home has a policy on selfmedication equipment to give residents the choice should a risk assessment demonstrate that this is appropriate. Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 10 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 &15 The home provides a range of leisure and social activities. Contact with relatives and friends is encouraged. EVIDENCE: The home has a visiting policy, which meets the National Minimum Standards. Residents stated friends and family are encouraged to visit the home and made very welcome. The visiting policy of the home is displayed in the foyer. The religion of each resident is recorded in their individual file. The registered manager said that a minister visit every six weeks to offer Communion. Residents confirm that activities are provided on a daily basis. There are bingo sessions organised, residents are taken out for short journeys and entertainers visit the home. A poster advertising an entertainer visiting the home on the 14th of February was seen during this inspection. A resident stated “I have a very good lifestyle here. The staff are very kind. If I had a complaint I know I could raise it with staff, who are very understanding. The food is good we are offered a choice, I have no complaints at all about the home.” Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 11 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): 16,17 &18 The home has a complaints procedure, which is displayed in the home and is known to staff and residents. Residents are able to raise any complaints or concerns through this procedure or residents meetings. The home has policies and procedures in place to ensure that any suspicion of possible abuse is investigated. EVIDENCE: The home’s adult protection policy is in line with current local guidelines. A copy of the Lincolnshire County Council adult protection procedure is included in the homes policy and procedures manual. Staff interviewed stated that they had read and understood both documents. Staff had a good knowledge of the types of abuse that could occur and the actions that they must take if they had any concerns. Staff comments and training records demonstrated that staff had received appropriate training in this subject which would help them to recognise and take appropriate action should the need arise. The homes complaints procedure was discussed in the formal interviews. Staff were familiar with this policy and stated it was displayed in the care home. Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 &26 Residents live in a home with a clean, comfortable and home environment. The health and safety policy of the care home is being followed. EVIDENCE: The home has a rolling maintenance program at present new thematic valves are been fitted to all hot water pipe systems. There are two areas of the home where hot water pipes have a surface temperature of 53°F these are to be boxed in. The home itself was clean tidy and smelt fresh. Residents stated that it is a comfortable nice home to stay in. Staff confirmed it is a safe environment in which to work. Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 13 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 & 30 There are sufficient staff on duty to meet the needs of the Residents, and staff have the skills and experience necessary to carry out their roles. The recruitment policy of the care home is being followed. EVIDENCE: Staff interviewed confirmed that they feel there is always sufficient staff on duty to meet the needs of residents. They stated that the staffing rota is always met and there is additional staff brought on duty if the need arises. The home has a training plan in place for the next 12 months. Staff confirmed in their formal interviews that training is being offered which is linked into supervision and appraisals. Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 14 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): 31,32,33,36 & 38 The home is well run, with good leadership and guidance from the registered manager who has worked for many years in the provision of community care. The health and safety and welfare of Residents is promoted. EVIDENCE: The home has a registered manager who is supported by a deputy manager. The registered manager as many years experience in the provision of community care. Staff stated that all members of the management team are approachable and supportive to staff. They stated teamwork is good and staff morale is high. There were no health and safety issues identified at this inspection. Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 15 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 x 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 3 15 x 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 x 3 Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 16 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 OP7 Regulation 15 Requirement Ensure that all residents have an up to date detailed care programme which includes an initial assessment, identification of all needs, detailed plan of how care will be delivered, regular evaluation review, risk assessments and residents agreement. Timescale for action 20/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Little Brocklesby House DS0000054666.V276300.R01.S.doc Version 5.1 Page 18 - 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!