Inspection on 08/11/05 for The Brake Manor

This inspection was carried out on 8th November 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 17/06/05

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 Ian Wright Unannounced Inspection 8th November 2005 09:15 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 The Brake Manor DS0000050568.V252556.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. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Brake Manor Address Bodmin Road St Austell Cornwall PL25 5AG 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) 01726 75748 01726 75752 Morleigh Ltd Mrs Patricia Jennifer Nancarrow Care Home 26 Category(ies) of Dementia - over 65 years of age (11), Mental registration, with number 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 DS0000050568.V252556.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Service users to include up to 11 adults aged over 65 with dementia (DE{E}) Service users to include up to 26 adults of old age (OP) Service users to include 1 named resident under 65 years Total number of service users not to exceed a maximum of 26 Service users to include up to 11 adults aged over 65 years with a mental illness (MD{E}) 17th June 2005 Date of last inspection Brief Description of the Service: The Brake Manor Care Home provides care for up to 26 older people; of which 11 may fall into the category of mental disorder or dementia. Day care is also provided by the registered provider. 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 by 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 the registered manager is Mrs Nancarrow. Mrs Nancarrow is currently working at another of the company’s homes, so the assistant manager Ms Angela Miners is responsible for the day to day management. The majority of the bedrooms offer en-suite facilities; many have pleasant views over the wooded valley. 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. Development plans however are currently on hold. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place in just over seven and a quarter hours. The inspection was unannounced. The inspector was able to speak to the majority of service users and met with Ms Angela Miners-the assistant manager and Mrs Juleff, one of the registered providers. The inspector examined the care and business records, and inspected the building. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 6 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 The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 7 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): 2, 3, 5 Service users are issued with a suitable statement of terms and conditions of residency /contract. A suitable pre admission assessment procedure is in operation to enable the registered persons to ascertain whether they can meet service users needs. Service users and their representatives are able to visit before formal admission is arranged. EVIDENCE: Ms Miners outlined a suitable process of assessment for service users who have recently moved into the home. Assessments were appropriately documented. Suitable care plans are subsequently developed from initial assessments. Service users and their representatives are able to visit before they have to make a decision to move in. A copy of the statement of terms and conditions of residency /contract is kept on individual service user files. Ms Miners said this is also issued to service users and / or their representatives. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 8 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, 10, 11 All service users have a suitable care plan which is regularly reviewed. Service users are treated with respect and dignity. A suitable policy regarding death and dying is in place. EVIDENCE: Suitable care plans were observed in individual service user files. There is evidence these are regularly reviewed. Staff were observed working with service users in a manner, which respects their privacy and dignity. Service users said staff are kind and sensitive in their approach. The registered persons have developed a suitable policy regarding the care of the ill and dying. Mrs Miners said care is given within the home as long as possible to those who are dying rather than service users having to move from the home. Suitable support from external professionals, such as district nurses, is provided. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 9 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 Routines and activities are suitable to meet individual service users needs. Service users can receive visitors when they choose. Appropriate procedures are in place to assist service users to maintain autonomy and choice. Meals provided for service users are to a good standard. EVIDENCE: Service users said they could get up and go to bed when they wished, and have autonomy how they organised their time. A pleasant relaxed atmosphere was observed on the morning of the inspection. It was clear there is genuine choice when service users can have their breakfast and get ready for the day. The registered persons employ a very enthusiastic and committed day activities co-ordinator. An excellent programme of activities is arranged so there is at least one activity most days. These activities are on offer to day care users and people who live in the home. These are well publicised in the hallway and include bingo, quizzes, movement to music, entertainers, and reminiscence. An aromatherpist also visits the home. A theatre company also has given a performance recently. Some external bus trips are arranged once or twice a year. Monthly visits occur from the Church of England Vicar. To improve this service further it is recommended the registered persons ascertain if visits from the library service would be useful to individual service users. Some books are available in the home and service users can have a daily newspaper / magazines. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 10 Suitable arrangements are in place for service users to receive visitors. Service users can meet with their visitors either in their bedrooms or one of several communal areas. Staff look after some service users moneys. Appropriate records are maintained regarding these. Records are kept of fees paid. The registered persons are recommended to provide information regarding advocacy services e.g. in the hallway and as part of the service user guide. Age Concern do however visit the home yearly to ascertain service user’s are well cared for. Service users are able to bring their own personal possessions with them when they come to live in the home. Unfortunately service users can no longer have pets in the home. Service users are able to access their personal records if they wish. The inspector shared a meal with service users, which was to a very good standard. Staff were observed providing appropriate support to service users during meal times. Appropriate arrangements are made for people with special diets. Drinks are available to service users throughout the day. A water cooler is available in the dining room. No cups were available for this on the day of the inspection. Ms Miners said she would address this issue. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 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 The registered provider has a suitable complaints procedure. Service users legal rights are protected. EVIDENCE: The registered provider has developed a suitable policy and procedure how service users, and other stakeholders, can make a complaint. This has been issued to service users (and where appropriate their representatives) as part of the service user guide. The registered persons or CSCI have not received any complaints in the last year. Service users legal rights are protected. Postal votes are arranged for service users. The registered persons are recommended to provide information regarding advocacy services e.g. in the hallway and as part of the service user guide. Age Concern however do visit the home yearly to ascertain care is satisfactory. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 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 The Brake Manor provides suitable facilities to meet the needs of service users. The home is generally well maintained, clean, comfortable and homely. EVIDENCE: The property is generally suitably maintained, appears to be safe, is comfortable and homely. For example furnishings and decorations are satisfactory. The home has been extensively refurbished in recent years. The property has extensive and pleasant gardens. There is an area outside the home where service users can sit. The home has several lounges where service users can choose to relax. Bedrooms were observed to be are pleasant, well decorated and the majority have en suite facilities. Service users all said they were happy with the facilities. Access is very good for example there is a stair lift and a passenger lift to the upper floors. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 13 Bathrooms and toilets are generally suitable. For example there is assisted baths / showers. However some of the toilets near the kitchen / office, although clean, are not particularly inviting. They would benefit from redecoration. A toilet seat in one of these was loose and needed fixing. The lock in the toilet on the first floor, at the top of the stairs needs to be repaired. One of ‘mosaic’ tiles in the hallway was missing and in need of urgent replacement as it presents a trip hazard to service users, visitors and staff. A paving stone by the office portakabin was broken and could present a trip risk. Mrs Juleff said she would ensure these matters are attended to as a matter of urgency. An immediate requirement was made regarding the tiling and paving stone. A large sign in the entrance to the staff area forbidding entry, detracts from the pleasant ambiance of the hallway and looks institutional. There is no legal requirement to have this, and if deemed necessary a small sign on the door would be satisfactory. It is recommended the sign should be removed. The home was clean and hygienic on the day of inspection. Suitable laundry facilities are provided. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 14 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 Suitable staffing levels are provided to care for service users. EVIDENCE: Rotas were inspected. At least four care staff are on duty from 0800 to 1200. From 1200 to 1500 2 carers are provided. Between 1500 and 2100 3 carers are provided. Two waking night staff are on duty at night. Suitable cleaning and kitchen staff are also employed. A day activities co-ordinator is also employed. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 15 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, 38 Suitable management arrangements are in place. Health and safety precautions need to be improved so service users are protected from health and safety risks. EVIDENCE: Mrs Miners said the registered manager is currently working at another of the company’s care homes. Mrs Miners is managing the home on a day-to-day basis. The Commission for Social Care Inspection has agreed to this arrangement for a three-month period. At the end of the period it has been agreed that the registered manager will return or a new application for a registered manager will be submitted. Good standards of care appear to have been maintained in this transition period. A suitable health and safety policy has been developed. Suitable professional checks on fire, gas and portable electrical appliances have been completed. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 16 The registered persons could not evidence that a hardwire test on the electrical circuit had been completed- although Mrs Juleff said this had been done. A copy of the test results must be forwarded to the commission. There is not a risk assessment for the prevention of Legionella. This must be completed and any control measures implemented. Health and safety risk assessments are very dated, need to be rewritten, and reviewed at least annually. An Immediate requirement regarding trip hazards is highlighted earlier in the report. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 2 The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38OP19 Regulation 13, 23 Requirement The registered providers must attend to the following repairs: • Replace paving slab by the office. • Replace missing ‘mosaic’ tile in hallway. (An immediate requirement was left regarding the above due to the health and safety risk-trip hazard.) Within the timescale given, the registered provider must notify the inspector in writing when this work has been completed. • Repair toilet seat • Repair lock in upstairs toilet. The registered persons must ensure satisfactory health and safety precautions are in place: • Evidence that a hardwire test on the electrical circuit must be provided to the Commission. • A risk assessment for the prevention of Legionella must be completed. Any control measures must be implemented. • Health and safety risk DS0000050568.V252556.R01.S.doc Timescale for action 14/11/05 2 OP38 13, 23 01/01/06 The Brake Manor Version 5.0 Page 19 assessments need to be rewritten, and reviewed at least annually. Staff (and where appropriate service users) must be made aware of the risk assessments. 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 OP12 OP17OP14 OP19 Good Practice Recommendations It is recommended the registered persons ascertain if visits from the library service would be useful to individual service users The registered persons are recommended to provide information regarding advocacy services e.g. in the hallway and as part of the service user guide. It is recommended the ‘Health and Safety / No entry sign is removed from the hallway. The Brake Manor DS0000050568.V252556.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection St Austell Office 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. 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