Inspection on 17/06/05 for The Brake Manor

This inspection was carried out on 17th June 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

The Brake Manor 04/10/06

The Brake Manor 08/11/05

The Brake Manor 02/02/05

The Brake Manor 08/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Brake Manor Bodmin Road St Austell Cornwall PL25 5AG Lead Inspector Elaine Bruce Announced 17 June 2005 9:00 a.m. 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. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Brake Manor Address Bodmin Road St Austell Cornwall PL25 5AG 01726 75748 01726 75752 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) Morleigh Ltd Mrs Patricia Jennifer Nancarrow Care Home 26 Category(ies) of Dementia - over 65 years of age (11) registration, with number Mental Disorder, excluding learning disability or of places dementia - over 65 years of age (11) Old age, not falling within any other category (26) The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include 1 named resident under 65 years Date of last inspection 020205 Brief Description of the Service: The Brake Manor Care Home provides personal and social care for up to 26 older people; of which 11 may fall into the category of mental disorder or dementia. Nursing care is not provided at the home, but the Community Nursing Team can provide limited nursing care when required. Day care is also provided by the home. The home stands in substantial wooded grounds of some 13 acres and is situated not far from the town centre of St Austell. It is accessible via a long driveway, with car parking for visitors to the main entrance. There are various seating areas, including a patio area near to the house. The home is owned by Mr and Mrs Juleff (Morleigh Limited) and is managed by Mrs Nancarrow who is the registered manager. The registered providers contintue to invest in both the upgrading of the property and the facilities for service users. The majority of the bedrooms offer en-suite facilities; many have lovely views over the wooded valley and are generally pleasant, light and airy. The communal areas are spacious, homely, well decorated and furnished. There is access to the patio and grounds from the main lounge. Stair lifts and a passenger lift are available to provide access to the upper floors. Morleigh Limited has acquired planning consent for a new care home to be built within the grounds, which will provide an additional 32 beds. This building will be required to register as a new premises with The Commission for Social Care Inspection. The home also operates a Domiciliary Care Agency Peace of Mind from the current premises. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 17th June 2005 over 7 hours and was carried out as an announced inspection. A tour of the premises took place and service users and staff were spoken to. Care records, staff files and policies and procedures were inspected. Positive feed back comment cards were received before the inspection from relatives of the service users. Only a small number of service users were spoken to during the course of the day. This is due to the quiz they were taking part in (and enjoying) during the morning and then again in the afternoon. One of the registered providers was present during the course of the inspection. What the service does well: What has improved since the last inspection? All the statutory and good practice recommendations of the inspection report dated the 2nd February 2005 have been addressed. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 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. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 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 The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 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 and 4 The home’s statement of purpose, brochure and service user guide documentation provide prospective service users with details of what the home provides helping an informed decision about admission to the home. Senior staff members are involved in the service user pre admission assessment procedure to ensure that the home will be able to meet their care needs. EVIDENCE: The home has a comprehensive statement of purpose, brochure and service user guide which are available to current and prospective service users. These documents, along with any other relevant information are presented as a pack in a colourful “Brake Manor” folder. Packs are available in the reception area of the home, and are given/sent to prospective service users on request. It is recommended that the room size information in the statement of purpose is converted into square metre measurements. The home has pre-admission assessments that are completed prior to a new service user moving into the home. Senior staff members will visit service The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 Page 9 users at home or in hospital (whenever possible) to ensure they can meet their care needs. Staff have the skills and experience required to deliver appropriate care to the service users within the home. Training has been given to the care staff which specifically addresses individual service user needs to include dementia care training. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 9 The service user’s health, personal and social care needs are being met by the staff and multidisciplinary staff as required. Medication is being administered correctly to the service users. EVIDENCE: Each service user has a plan of care which includes the health, personal and social care needs of the individual as well as comprehensive risk assessments. A life history of each service user is presently being brought together to be included in care planning. Pre admission assessments are kept within this documentation and form the basis of the care planning process. A comprehensive daily record is maintained which provides a record of the individual’s day including their social care needs and activities. Service users and or their representatives take part in the care planning process. It was noted during the inspection that staff have easy access to care planning documentation in a suitable environment. Service users have access to outside health care professionals. All the service users are registered with a general practitioner and currently the local community nurses visit the home twice weekly to attend to the health care The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 Page 11 needs of two of the service users. Direct observation would suggest that the home has a very good working relationship with the community nurses. The home seeks the advice of the community nurse with regard to the promotion of continence and prevention of pressure sores. Appropriate pressure relieving equipment is provided when required. A chiropodist visits the home on a six weekly basis, and dental and optical provision is made on a domiciliary basis as required. The home uses a monitored dosage “blister pack” medication system. Medication records were found to be completed appropriately on the day of the inspection. It is recommended that the medication policy and procedure be expanded to include more information on controlled drugs for example. Improvements are noted to the medication system generally in regard to good practice recommendations made in previous inspection reports. All staff who administer medication have received training and are due to attend training again which will be accredited as required by The National Minimum Standards. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the standards in this section were assessed on the day of the inspection. EVIDENCE: The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 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 and 18 The home has a comprehensive complaints procedure provided to the service users in the statement of purpose document. The home has in place adult protection policy and procedures and training to provide staff with the knowledge and understanding of adult protection issues to protect service users from abuse. EVIDENCE: The home has a comprehensive complaints procedure, giving timescales and stages for a response. This documentation is provided to the service users in the statement of purpose which is available in the Brake Manor folder. The home has an adult protection procedure that includes information on whistle blowing. In addition the “No Secrets” document is available to staff. Staff sign the documentation when they have read it (and watched the video) and then it is discussed in supervision sessions with the mentor that is assigned to the staff member. The manager has plans for all the staff to attend the local social services adult protection training when places are available. Some staff have already received this training. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 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) 19,20,21,22,23,24,25 and 26 The standard of the environment within The Brake Manor is good providing service users with an attractive and homely place to live. EVIDENCE: Improvements are ongoing externally and internally at the home. Many improvements have been made over the years by the current registered providers. The grounds around the home are very pleasant with attractive seating areas and walks. The service users have access to the grounds from the main entrance and the lounge area. The home offers pleasant communal space comprising of a light and spacious garden room/lounge and a smaller lounge. The main dining area is also very pleasant with a smaller dining area provided primarily for day care provision. Lighting and furnishings in all communal areas is domestic in nature and furnishings are of a good quality. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 Page 15 The home provides toilet, washing and bathing facilities that are suitable to meet the needs of the service users. The majority of the bedrooms have ensuite facilities (19 single and 1 double) comprising of a toilet and a wash hand basin. The home has two assisted bathrooms and also a medic bath/shower. There are accessible toilets for service users close to the dining areas and lounge areas. All bathroom and toilets are clearly marked. The service users are provided with the specialist equipment that they require to maximise their independence. The home provides both stair and passenger lifts, hand and grab rails, bathroom aids and a wide range of mobility aids. There is a call bell system which is accessible in every room. All maintenance records are in place as required for regular servicing of all equipment in the home. Twenty two of the bedrooms have at least 10 square metres of usable space. The two double rooms are both at least 16 square metres. Many of the bedrooms are personalised by individual service users who have brought their own possessions with them. This is encouraged. The majority of the bedrooms offer single occupancy however screening is provided where a room is shared. Many of the bedrooms have very attractive views over the wooded valley. Some to the bedrooms at the rear of the home are a little dark. All rooms are naturally heated and naturally ventilated. Radiators are guarded and taps to baths and hand basins have pre set valves to ensure safe bathing water temperatures. The laundry facilities are satisfactory with all laundry duties undertaken by a housekeeper. The housekeeper also covers cleaning duties from a Monday to Saturday morning, with care staff undertaking additional cleaning as required. It was noted that although the home was generally very clean odour control could be improved in the double bedrooms. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 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 and 30 Staffing levels are appropriate to meet the needs of the service users. Staff training is very much encouraged and taken up by all staff. EVIDENCE: The home employs 5 carers for the busy morning period with three carers in the afternoon and two waking night staff members. In addition the manager is on duty. It was though noted on the day of the inspection that due to staff sickness on the day staff were very, very busy due to being one short. 13 of the care staff have an NVQ 2 qualification, which is 65 of the staff. In addition there are approximately 4 staff who will also be undertaking this training soon. The team leaders are qualified to NVQ 3 and one of the senior carers is undertaking an NVQ 4 in care. Staff files are in good order with evidence of completed application forms and two written references and criminal records bureau checks being in place. The home has an induction programme for new staff members. This induction covers the principles of care. Dementia training is being undertaken by staff members at this time as a priority with first aid training to follow after. Good practice training regularly takes place to include for example parkinsons and diabetes. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 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 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) 31,32,33,34,35 and 36 The manager is supported well by the senior staff (and registered providers) in providing clear leadership throughout the home. EVIDENCE: The registered manager has completed the registered managers award and is qualified to NVQ level 4 in care management. She has recently undertaken dementia awareness training and employment law training. There are clear lines of accountability within the home with a senior management team in place. The registered providers are in day to day contact with the home. One of the registered providers undertakes the general maintenance within the home. The registered manager is involved in meetings with the independent sector and attends any courses that The Commission for Social Care Inspection run. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 Page 18 The staff and service users spoke positively about the manager and her style of running the home. Regular meetings are taking place with the staff to involve them in the running of the home but at this time these meetings are not minuted. In January of this year the registered manger undertook a quality audit of the running of the home to include developing a questionnaire for the service users, relatives and day care clients. Very positive feed back was given in the documentation on the running of the home. The registered manager has evaluated all the findings. The financial viability of the home is confirmed from the registered providers accountant. The registered manager ensures that the service users control their own money. If a service user does not wish to, or they lack capacity a relative, power of attorney or trusted friend is appointed to act on their behalf wherever possible. Monies are held on behalf of several service users that are kept individually with receipts and records maintained. Two of these accounts were checked at random and found to be correct. A staff member is employed for these duties. The home has in place an established formal supervision programme for staff. Written records are maintained on file. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 2 3 3 3 3 x x The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 Page 20 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 Regulation Requirement None at this inspection 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 1 9 32 Good Practice Recommendations To convert the room size information in the statement of purpose into square metres. To expand the medication policy and procedure to include more information on controlled drugs. To evidence the staff meetings that are taking place at the home. The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell, Cornwall PL25 4AD 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 The Brake Manor D52-D04 S50568 The Brake Manor V222718 170605 Stage 4.doc Version 1.30 Page 22 - 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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