Inspection on 19/01/06 for Stildon Brendoncare

This inspection was carried out on 19th January 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.

Other inspections for this house

Stildon Brendoncare 12/08/08

Stildon Brendoncare 05/06/06

Stildon Brendoncare 26/08/05

Stildon Brendoncare 07/12/04

Stildon Brendoncare 27/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Stildon Brendoncare Dorset Avenue East Grinstead West Sussex RH19 1PZ Lead Inspector Mrs J Hough Unannounced Inspection 19th January 2006 08:30 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 Stildon Brendoncare DS0000014746.V273475.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. Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stildon Brendoncare Address Dorset Avenue East Grinstead West Sussex RH19 1PZ 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) 01342 305750 01342 328337 The Brendoncare Foundation *** Post Vacant *** Care Home 32 Category(ies) of Dementia (4), Dementia - over 65 years of age registration, with number (4), Old age, not falling within any other of places category (32), Physical disability (4), Physical disability over 65 years of age (4) Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Only service users aged 55 years and over may be admitted. The total number of service users accommodated must not exceed 32 at any one time. 26th August 2005 Date of last inspection Brief Description of the Service: Stildon Brendoncare is a purpose built home providing personal care and nursing care for thirty-two persons over the age of sixty-five years but has a variation to enable the admission of the following: Old age not falling within any other category (32) Physical disability (4) Physical disability over 65 years of age (4) Dementia (4) Dementia over 65 years of age (4). The accommodation comprises of thirty-two single rooms all with en-suite facilities. The accommodation is arranged on two floors each having a sitting room, dining room and two large bathrooms. The home is located within a short distance of East Grinstead town centre with its shops and leisure facilities. The home is owned by The Brendoncare Foundation and the Responsible Individual is Mr Ronald Staker and the Registered Managers post for the home is at present vacant. Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 6 hours and the senior member of staff on duty on the day provided the information required. A tour of the building took place and eight residents, four members of staff and one visitor were spoken with. Records were examined with regard to the resident’s assessments and care plans, medication, complaints, accidents and incidents and maintenance checks. Not all the standards were inspected on this inspection and those not covered were fully met at the last inspection in August 2005. What the service does well: What has improved since the last inspection? There have been no improvements made since the last inspection. Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 6 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. Stildon Brendoncare DS0000014746.V273475.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 Stildon Brendoncare DS0000014746.V273475.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): 1,2,3,5. The Statement of Purpose and terms and conditions of the home need updating. EVIDENCE: The Statement of Purpose for the home needs updating to reflect that the Registered Managers post is at present vacant. A copy of the resident’s contract and terms of conditions was examined that included all the relevant details. However, the title of the Commission given on the contract needs updating to reflect the Commission for Social Care Inspection (CSCI). All new residents have a full assessment of their needs carried out prior to admission to the home that is carried out by the Registered Manager or a senior member of staff from the home. The residents or their relatives are able to visit the home and move into the home on a trial basis if needed. Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 9 Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. The resident’s care plans and assessments were not consistent in all cases. The medication records were well maintained. The home has policies and procedures for caring for the dying resident. EVIDENCE: On examining six of the resident’s assessments and care plans it was noted that different paperwork and formats for the care plans were still being used. Generally the care plans seen were well written, and identified the needs of the residents and the level of assistance required. However two of the care plans and assessments need reviewing to ensure all the identified needs of the residents are reflected on the care plan and on all the risk assessments. All the care plans were reviewed monthly and signed by the resident or their relatives where possible. The residents spoken with said they were happy with the care they received and all appreciated what the staff did for them. The medication administration records were examined and found to be accurate and well maintained. All appropriate records were kept of medication received and disposed of by the home. The administration of all Controlled Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 11 Drugs were recorded in a separate register and checked and signed by two members of staff. The aims and objectives of the home highlight the importance of staff respecting the privacy and dignity of the residents. This is also included in the induction training for all new staff coming to work in the home. The residents spoken with confirmed that they were given choices with regard to what they wanted to do and how they were looked after. The home had a policy on care of the dying resident, and some of the staff had attended training on care of the dying. The home endeavours to continue to care for the dying resident, unless there are strong medical reasons that prevent this. The relatives and friends of the dying resident are able to stay if the resident wishes, and if needed accommodation is available for them to stay overnight. Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 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 the following standard(s): 12 The activities in the home are arranged to suit the wishes of the residents. EVIDENCE: The activity organiser spoken with had recently started working in the home and was in the process of getting to know the residents and discussing with them their interests and preferences for social events and activities. The activities provided at present include art and craft sessions, quizzes and assorted games. The friends of Stildon arrange occasional trips out and a church service is held each month. Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 13 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. The home has a clear and accessible complaints procedure. The home supports those residents who wish to vote. Information on advocacy services is accessed when needed. EVIDENCE: The complaints procedure for the home clearly sets out how, and to whom you should make a complaint, and the process that follows. The title of the Commission on the complaints procedure requires amending to reflect the Commission for Social Care Inspection. The complaints log was examined and one complaint had been recorded since the last inspection in August 2005. The complaint had been fully investigated and a letter of response sent to the complainant that was awaiting an outcome. Minor complaints or concerns that can be dealt with at the time were not generally recorded in the complaints log. Arrangements for postal voting are made for those residents who express a wish to vote in local elections. Information on advocacy services would be provided as needed for those residents who need someone to represent them and speak on their behalf. Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 14 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): 22,26 All areas of the home were kept clean and hygienic. The home provides specialist equipment and aids for the residents. EVIDENCE: On touring the home it was found to be clean and fresh in all areas. On speaking with the residents it appears there had been problems in the past with the standard of cleanliness in some areas of the home but lately it had improved. The home provides the equipment and aids necessary for the residents and all the resident’s rooms have the facility of a call bell. However, concerns were raised by a resident and a relative, who said they were worried what might happen if a resident fell in an area where they could not access the call bell system. Apparently in the past the residents were given pendants to wear so that they could summon assistance in all areas of the home including outside, Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 15 but this was no longer available. Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 16 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): 27,29. The staffing numbers are sufficient to care for the residents. Staff files must contain evidence that all the appropriate checks have been carried out prior to employment. EVIDENCE: The staff rota’s showed that the staffing numbers had been maintained since the last inspection in August 2005. At present the home has some care staff vacancies and uses agency staff to cover vacant shifts. The residents spoken with felt the staffing numbers were sufficient to meet their needs, and none expressed concerns about the time they had to wait for assistance. The staff spoken with also felt there was enough staff on duty to look after the residents. Three files were examined for new staff working in the home. Two of the files contained all the relevant information and documents. However, one file did not contain evidence that a satisfactory Criminal Records Bureau check had been received and only had evidence of one reference. However, on speaking with the member of staff it was confirmed that all the necessary checks had been carried out prior to employment. The member of staff had worked for the Brendoncare Foundation in another establishment where the checks were carried out. Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 17 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): 31,32,33,34,36,38. The care staff do not have formal staff supervision as required. A review of the in-house maintenance checks is required. The home gains the view of the residents with regular meetings and resident’s surveys. EVIDENCE: The registered managers post for the home is vacant. The deputy manager is acting manager at this present time. The recruitment for a new manager is apparently taking place in February 2006. To enable the home to gain the views of the residents on the service they provide, resident’s meetings are held every six months with the Chief Executive of the Brendoncare Foundation, plus annual questionnaires are sent to the residents or relatives. The home is planning to send the questionnaires out again in January 2006. Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 18 The home has a policy not to get involved with the finances of the residents. The home only handles small amounts of spending money that was recorded for each resident, and any transactions were recorded and receipts kept where appropriate. On speaking with the staff it was apparent that formal staff supervision is still not taking place that is recorded and kept on their confidential file. However, the staff have reflective practice sessions as part of their work performance. The maintenance records showed that systems and equipment in the home were maintained and serviced by suitable contractors within agreed timescales. The in-house checks carried out by the maintenance men were recorded in the maintenance log. It was noted that the water temperatures were only monitored and recorded in the bathrooms, and not in the resident’s rooms due to them having water temperature regulators fitted. Window restrictors were fitted to all the windows on the first floor except for the dining room. No evidence was recorded that the window restrictors or the paths outside were checked regularly for the health and safety of the residents and staff. Generally all accidents, incidents and injuries were correctly recorded and reported to the appropriate authorities. On checking the number of incidents and accidents that had occurred in the home since the last inspection it was noted that an accident resulting in a serious injury had been recorded as an incident rather than an accident. On speaking with the staff it appears that regular training is provided for first aid, manual handling, fire safety, food hygiene and infection control. Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 19 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X X X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score N/A N/A 3 3 X 2 X 2 Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 20 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 OP36 Regulation 18(2) Requirement The registered person shall ensure that persons working in the home receive formal staff supervision. (Timescale not met 30th November 2005.) Timescale for action 28/02/06 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. 2 Refer to Standard OP7 OP1 Good Practice Recommendations A format for the residents care plans should be agreed and used by all the nursing staff. Assessments and care plans must reflect all the present needs. The Statement of Purpose should reflect the post for the manager of the home is vacant. 3 OP38 All in-house maintenance checks should be recorded in the maintenance log and should include window restrictors, and water temperatures in all areas of the home. Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 21 Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection 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 Stildon Brendoncare DS0000014746.V273475.R01.S.doc Version 5.0 Page 23 - 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. 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