Inspection on 26/08/05 for Stildon Brendoncare

This inspection was carried out on 26th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stildon Brendoncare 12/08/08

Stildon Brendoncare 05/06/06

Stildon Brendoncare 19/01/06

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 London Road East Grinstead West Sussex RH19 1PZ Lead Inspector Mrs J Hough Announced 26 August 2005. V236641 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. Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Stildon Brendoncare Address London Road, East Grinstead, West Sussex, RH19 1PZ 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) 01342 305 750 01342 305758 Mr Ronald Staker Mrs Helen Winter Care Home (CRH) 32 Category(ies) of Physical disability (PD) - 4, Dementia - over 65 registration, with number years of age (DE(E)) - 4, Dementia (DE) - 4, of places Physical disability over 65 years of age (PD(E)) 4 Old age, not falling within any other category (OP) - 32 Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Only residents aged 55 years and over may be admitted. The total number of residents accommodated must not exceed 32 at any one time. Date of last inspection 7/12/04 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 Manager responsible for the day to day running of the home is Mrs Helen Winter. Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over 8 hours and the registered manager and the deputy manager were present at the inspection and provided the information required. The pre-inspection questionnaire and the comment cards from the Commission completed by the residents and their relatives, provided further information. Staff files, resident’s care plans and assessments, complaint and accident records were all examined. A tour of the premises was made and some of the resident’s rooms were seen. Twelve residents, and six members of staff were spoken with, to find out their views on what it was like living and working in the home. What the service does well: What has improved since the last inspection? Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 6 The extra care flats have been registered as a domiciliary care service. 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 H60-H11 S14746 Stildon Brendoncare V236641 260805 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 Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 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 & 4 The Statement of Purpose needs reviewing. The staff are trained and experienced to carry out their work. EVIDENCE: The Statement of Purpose for the home is generally brief in content, and does not include the admission process and any criteria for admission. Anyone wanting information about the home is also given a Welcome booklet that includes the complaints procedure and the Service User Guide. The information provided on the pre-inspection questionnaire with regard to staff training, and speaking with six members of staff it was clear that the staff have the skills and experience to provide a good standard of care to the residents. Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 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 standard(s) 7,8, & 9 The format used for the resident’s care plans is not consistent. The medication policies and procedures for the home ensure safe practice. EVIDENCE: On examining the care plans and assessments of five residents it appeared that different formats were being used for each of the care plans. On speaking with the nursing staff it is clear that they are not sure which format to use. One care plan seen did not include the level of assistance needed from the care staff for washing and dressing, although it had been identified as a need on the resident’s assessment. Although care plans were dated and signed as having been reviewed each month some of the information documented on one of the resident’s assessment and care plan did not reflect all the present needs. However, on speaking with the residents it was clear that their needs were being met by the care staff, and they said the staff were always kind and considerate. Further evidence was taken from the completed comment cards that showed that generally the residents felt well cared for and felt the staff treated them well. The medication administration records examined were accurate and well maintained. All appropriate records were kept of medication received and disposed of by the home. The arrangements for disposal of medicines had Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 10 been changed to a licensed company but there were concerns with how the disposed medication was being stored loose, in a large plastic container. The disposal of Controlled drugs was satisfactory being that they were dissolved in a jelly substance contained in a jar with a lid. The residents who were assessed as able to take their own medicines had signed a self-medication assessment and had a lockable space in their room to safely store their medicines. The home had a homely remedies list that was agreed and signed by the GP for those medicines that could be given to the residents when needed. All controlled drugs were stored in a metal cupboard and administration was recorded in a separate register. All the necessary equipment was provided for the prevention and treatment of pressure sores. Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13, 14 & 15 The activities provided are appropriate to meet the resident’s needs. The home offers a well- balanced and nutritious diet. EVIDENCE: The home employs two activity organisers who arrange activities at least three times per week to suit the interests and choices of the residents. The activities include quizzes, games, skittles etc. and in addition there are church services, league of friends coffee mornings, and the occasional entertainment. A physiotherapist visits the home once a week. The residents spoken with felt the activities provided were suitable and said there was nothing they would like that is not already provided. The residents confirmed that they could have visitors at any reasonable times either in their own room or in the communal areas, and the staff always made their visitors welcome. The home does not handle any of the financial affairs of the residents and this responsibility lies with their relatives/representatives. Some of the resident’s rooms were seen to contain their own possessions and small items of furniture. The menus seen for a four- week period offered a good choice of well-balanced food. The residents spoken to in the dining room praised the food and said it was tasty and there was plenty to eat. Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 12 Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 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 standard(s) 16 & 18 The home has a simple and clear complaints procedure EVIDENCE: The complaints log was examined and there was one recorded formal complaint that had been fully investigated and resolved satisfactorily. Minor complaints that can be dealt with at the time are not generally recorded in the complaints log. The home has the West Sussex Adult Protection procedures in place for reference purposes. The staff have attended training on abuse and further training is planned for January 2006. The members of staff spoken with understood their responsibilities in reporting any suspicions or allegations of abuse within the home. Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 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 standard(s) 19,21,22,23,24,25,26 The residents live in safe, comfortable and well-maintained home. EVIDENCE: The home provides high quality accommodation with all areas in the home being decorated and furnished to a high standard. Throughout, the home has fitted carpets, quality soft furnishings and some attractive colourful prints displayed on the walls. Some of the residents had chosen to furnish their rooms with their own possessions and small items of furniture. All rooms have electrically operated beds. There are four assisted bathrooms and a number of additional toilets in the home for the resident’s use. The home was clean and fresh on the day of inspection and the residents confirmed that all areas of the home were always kept spotlessly clean. The laundry facilities are spacious with two industrial washing machines and Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 15 driers and a deluxe ironing system. The laundry was clean and tidy on the day of inspection. Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 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 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 staffing numbers are sufficient to provide a good standard of care to the residents. The staff are experienced and qualified to carry out their jobs. EVIDENCE: Staff rota’s show that there are 2 trained nurses and 5 care assistants on duty in the morning, and 2 trained nurses and 4 care assistants in the afternoon. At night there is 1 trained nurse and 3 care assistants. The home does not have any care or nursing staff vacancies and agency staff are only used to cover vacant shifts due to holidays and sickness. Nine of the care staff working in the home are qualified to NVQ Level 2 or 3 in care. When speaking with the staff they felt the staffing numbers on each shift was appropriate for them to provide a good level of care to the residents, and on speaking with the residents they confirmed they were well looked after. The residents also felt that the staff generally responded quickly to any calls for assistance, but said it varied according to the time of day. In the past concerns were raised with regard to the staffing levels when staff were needed to attend to the residents living independently in the extra care flats. On discussion with the deputy manager who is responsible for the residents in the flats she confirmed that staff in the home only attend to the very rare emergency call, and it did not cause a problem with the staff numbers in the home. Staff files examined showed that all staff are employed following two satisfactory written references and a Criminal Records Bureau and POVA check, Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 17 and all the relevant documents are in place. A list of training undertaken by the staff from April 2005 to August 2005 and future planned training to February 2006, shows that the home provides the staff with a varied programme of training opportunities. Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 18 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) 35,36,37 & 38 The nursing and care staff do not receive formal staff supervision. The home protects the residents and staff from harm as far as practicable. EVIDENCE: The home’s policy is not to act as company appointees for any of the residents. Secure facilities are provided for the safekeeping of money or valuables on behalf of the residents. On speaking with the staff it was apparent that the care and nursing staff are not having formal staff supervision arranged at least six times a year, which is documented and kept on their confidential files. However all staff are supervised and supported as part of their daily work practices. There was no evidence that training had been provided for senior members of staff to carry out formal supervision. The residents can have access to all their personal records if they wish, and their individual care plans are discussed, drawn up and agreed with them. Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 19 The information provided on the pre-inspection questionnaire showed that all equipment and services in the home are regularly serviced and checked. Staff have attended regular training in manual handling, first aid, fire safety and infection control. The home has a policy of recording all incidents and accidents whether an injury is sustained or not. Incidents are situations that are not witnessed and are therefore recorded in the incident book unless an injury is sustained, when it is recorded in the accident book. On examining the accident book there were 19 accidents recorded from January 2005, two of which resulted in the residents being admitted to hospital. Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 20 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 2 N/A N/A 3 N/A N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 N/A 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 N/A 4 4 4 4 N/A 4 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 N/A 3 N/A N/A N/A N/A 3 2 3 3 Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 21 No Are there any outstanding requirements from the last inspection? 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 36 Regulation 18(2) Requirement The registered person shall ensure that persons working in the home receive formal supervision. Timescale for action 30th November 2005 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 7 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 present needs. Stildon Brendoncare H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West SUssex BN11 1RY 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 H60-H11 S14746 Stildon Brendoncare V236641 260805 Stage 4.doc Version 1.40 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. 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. 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