Inspection on 03/05/05 for The Briars

This inspection was carried out on 3rd May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Briars 19/09/07

The Briars 21/09/06

The Briars 06/02/06

The Briars 22/09/04

The Briars 28/04/04

Similar services:

Craigmore House

1 Lanark Close

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

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

CARE HOME ADULTS 18-65 The Briars 24 Pearl Street Saltburn-by-Sea TS12 1DU Lead Inspector Penni Hughf Unannounced 03 May 2005 14:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Briars Address 24 Pearl Street Saltburn-by-Sea TS12 1DU 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) 01287 622264 Mr V Game Mrs M Game Care Home 3 Category(ies) of LD -Learning Disability registration, with number of places The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22 September 2004 Brief Description of the Service: The Briars is a single-fronted, Victorian terraced house, which blends in well with the surrounding properties. There is a small garden to the rear of the property. The home is situated in an established residential area of Saltburn, close to shops, community facilities and a short distance from the seafront and the Valley Gardens.Accommodation is provided in three large single rooms, each containing a wash hand basin. Communal faciliities consist of a comfortable, family style lounge, a dining room and a kitchen, and there is an office for the use of the manager and staff. The dining room is a large functional room, which is also used as an activities room and residents have access to all domestic facilities. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took 5.5 hours over two days and was carried out as one of the two statutory inspections required by the Care Standards Act 2000. A partial tour of the premises took place and staff and care records were inspected. Two staff on duty were interviewed, and one spoken to, together with all three residents. This was an unannounced inspection, and there were no visitors during the time the inspection took place. What the service does well: What has improved since the last inspection? Four of the five requirements from the last inspection have been met satisfactorily, with the outstanding requirement, for staff to complete a medication course, being partially met, with staff currently undertaking the course. Since the last inspection, the manager/provider as completed her NVQ level 4 qualification The Briars v224941 b51-b01 s96 the briars v224941 030505 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 Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,4 &5 Pre-admission procedures are thorough, ensuring residents needs will be met. The terms of residence are insufficient and do not provide adequate information about fees and trial periods. EVIDENCE: The care management assessment and care plans, undertaken prior to the admission of the last two residents to be admitted to the home, were examined and found to contain all the elements required by this standard. There was considerable evidence of input from both social and health care professionals and awareness of legislation. There had been no further admissions to the home, and the care plans looked at on this occasion still contained this information. All three residents files contained terms of residence, signed and dated by the resident and the provider/manager. However, there needed to be clarity about the agreement with the resident, should the trial period not work out and the resident not be made permanent. The terms of residence should also state quite clearly, what that individual paid each week for their care and accommodation. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 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 staff have a good understanding of the residents’ support needs and this is evident from the positive interaction observed between staff and residents and knowledge base displayed by staff at interview. EVIDENCE: There were some limits placed on resident’s choices as the result of multidisciplinary Care Plan Approach meetings regarding ability and risk, but where possible residents were encouraged to be independent. These limits were identified in the residents care plans. Staff said that choices were encouraged about food, clothes, leisure activities and family involvement. Residents spoke about their favourite foods, changing the décor in their rooms and liking the staff. Residents said that they liked shopping with the staff and the staff helped them when buying clothes. Staff confirmed that they gave residents guidance when buying clothes, as sometimes choices made were inappropriate. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16 & 17 Residents are well supported and take part in a variety of college and leisure activities with their wishes being taken into consideration. Dietary needs are well catered for with a well balanced and varied selection of food available meeting residents tastes. EVIDENCE: Two residents interviewed said that they attended college one day a week, and this was confirmed by staff and care plans. One resident said that she really enjoyed going to college, where she attended an arts and crafts class. The manager said that she was currently working towards another day a week for the resident to attend, and the resident said that she would like to go more frequently. The third resident attended a day centre five days a week, where she participated in a number of activities. Staff and residents said that residents had a choice of leisure facilities – they attended Loftus Leisure Centre, using the swimming pool, the gym and the Jacuzzi. In addition, they use the cinema and the local pub, as well as the Grenfell Club on Friday nights. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 11 There was clear evidence in the action plans that residents were consulted, and their likes and dislikes, wants and wishes, incorporated into their plans. Residents’ meetings took place every two months and minutes were evidenced, which identified discussions took place around how leisure time should be spent and where residents wanted to go for their holidays. There was evidence in one resident’s care plan, about supporting her wishes about how and when she had contact with certain visitors. Residents spoke of the different meals that they enjoyed, citing curries, quiches, salads, with Indian and Chinese takeaways being a favourite. Staff confirmed that the residents were offered a wide choice of meals, which offered an enjoyable and well balanced diet. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 & 20 The health and personal care needs of residents are well met, with evidence of good multi disciplinary working taking place on a regular basis. Administration of medication is generally well-managed promoting good health, but lack of communication between staff and manager could place residents at risk. EVIDENCE: The home was committed to using external resources to meet the needs of the residents in their care and there was evidence on care plans of ongoing input from both health and social work professionals. Two of the three residents were subject to CPA requirements. Since the last inspection, the venue for these meetings had changed from the offices of the psychiatrist, to The Briars. The manager said that these had made the meetings far less stressful for the residents and residents said they preferred having meetings at the home. The visitors’ book confirmed the date of the last CPA meeting and the actions decided at the meeting were evidenced on the residents file. An external advocate was involved for support of one of the residents. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 13 Residents spoke of being happy at the home. Each of the three residents had their own key worker from the four staff members. All care was provided by same gender carers. Care plans held detailed information about what support residents needed and how it should be provided. Risk assessments were completed in conjunction with health care professionals. Since the last inspection, photos of the residents had been introduced onto their medication “sleeves,” to reduce risks of misadministration. All staff were currently undertaking a Safe Handling of Medicines course, which was a Distance Learning course with Stockton Riverside College, which would be Asset certificated on completion. When checking the MAR sheets, it was noticed by the inspector, that the dates on the sheets were a month out, i.e. Monday 4.4.05 instead of 2.5.05. This had been seen by the staff, who had altered the dates, rather than informing the manager and returning the sheets to the pharmacy for replacement. During the inspection, the MAR sheets were replaced by the pharmacy. Staff and manager were reminded of the importance of following procedure by checking all details on the MAR sheets on every occasion, and ensuring that any errors are rectified by the pharmacy. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Knowledge of procedures for the protection of residents is not satisfactory and this places them at possible risk of harm. EVIDENCE: A complaints book was in place, but contained no entries. The home had a policy and procedure to deal with complaints, and this included the address and telephone number for the Commission for Social Care Inspection. The Commission had received no complaints during the last twelve months. Residents said that the staff listened to them. There had been no allegations of abuse at the home. Clear procedures were in place in the care plans for staff to follow if residents became physically or verbally aggressive. However, staff when interviewed, were unsure of the correct procedure to follow should an allegation of abuse be made when the manager wasn’t present, and the manager displayed some confusion about the difference between No Secrets Adult Protection, and POVA (protection of vulnerable adults.) The “No Secrets” guidance was available in the home, and the manager and the staff must ensure that they familiarise themselves with the information held in it, together with the homes own policy and procedure. The manager must ensure that she keeps up to date with any changes in legislation or procedure regarding Adult Protection. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,27 & 30 The home continued to provide a comfortable, well-maintained and safe environment for the residents and their visitors. EVIDENCE: All three residents were accommodated in spacious single rooms with wash hand basins, which met the requirements of the standard. All three bedrooms were spacious and airy, and included a wash hand basin. Residents told the inspector that they had chosen their own décor and soft furnishings. Radiators in the residents’ rooms were not provided with covers, but all three care plans contained risk assessments, which identified low risk from them. These had been reviewed on the 26.04.05. Water temperatures in wash hand basins fell within acceptable parameters. The home provided one bathroom and one shower room, and sufficient lavatories to meet the requirements of the National Minimum Standards and the residents. A bath thermometer was available in the bathroom and staff said they used it whenever a resident had a bath. The kitchen and laundry were domestic in scale and style, and the shared space facilities were ample for the residents living at the home, and met the National Minimum Standards. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 16 On the day of the inspection, the home was seen to be clean and safe, with no unpleasant odours. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,34 &35 Recruitment procedures are robust, and staff morale is high resulting in an enthusiastic and tight knit team that works positively with the residents to improve their whole quality of life. EVIDENCE: Personnel files had been developed to include all the information required, as set out in Schedule 4(6), Regulation 17(2) of the Care Homes Regulations 2001. Since the Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004 came in to force on the 26th July 2004, there was no longer a requirement for a copy of an employee’s birth certificate and passport to be kept in the home and this information had been passed on to the manager at the last inspection. All four staff files included a signed statement by the staff member that they were both physically and mentally fit for the purposes of the work they perform. The files included job descriptions and evidence of training undertaken as well as the General Social Care Councils Codes of Practice for Care Workers. The latest member of staff was commenced her employment on 24.01.05, and her CRB and POVA checks were received 21.01.05. The manager was not familiar with the POVAFirst procedures, but this did not impact on residents, as The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 18 her policy is to wait until she receives the CRB and POVA disclosure before commencing any new staff’s employment. Nevertheless, the manager must ensure that she familiarises herself with all aspects of the legislation to ensure compliance. All staff were currently undertaking a Safe Handling of Medicines course, and had just completed an Infection Control Course, confirmed by their trainer from Stockton Riverside College. The latest staff member said that she is doing her first aid in June this year. Three staff held NVQ level 2 in care, with the newest member of staff intending to enrol in September 2005. One member of staff also held NVQ level 3 in care, with a second member of staff planning to take her level 3 next year, 2006. Regular staff meetings took place, the last two minutes recorded being 6.1.05 and 22.3.05. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 & 38 Staff are well supported by the manager and were confident in the leadership provided. Residents’ rights and needs are protected by the management approach of the home. EVIDENCE: Since the last inspection, the registered manager had completed modules RM 1 and 2 that she was required to achieve, in order to meet the requirement to hold a qualification at level 4 in both management and care by 2005. She was awaiting her final marking. Staff said that the manager’s style was open and supportive; they had regular staff meetings, formal supervision and ongoing informal supervision. They said the manager had an open door policy and was always available to them for support and advice. The staff and those residents able to give an informed opinion said they thought the home was well run. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 2 Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Briars Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x x x v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 21 yes 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 YA20 Regulation 13 Requirement Timescale for action 01/08/05 2. YA5 17 3. YA20 13 4. YA23 13 The registered manager must ensure that all staff complete the course on the handling of medication. Previous timescale of 01/08/04 not met. The residents terms of residence 01/06/05 must include specific fees, information re. trial period and residents room number. All MAR sheets must be checked 03/05/05 for errors on receipt from the pharmacy and returned to be rectified if any errors noted. The registered manager must 01/06/05 ensure that she keeps up to date with any changes of legislation or procedure regarding Adult Protection and POVA and keeps staff informed. 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. Refer to Standard YA37 Good Practice Recommendations The registered manager/provider should ensure that she receives her certificate for units RM 1 & 2 of the Registered v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 22 The Briars Managers Award 2005. The Briars v224941 b51-b01 s96 the briars v224941 030505 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unit B, Advance St Marks Court Teesdale Stockton-on-Tees TS17 6QX 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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