Inspection on 30/08/05 for The Briars

This inspection was carried out on 30th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Briars 24/06/09

The Briars 27/06/07

The Briars 20/06/06

The Briars 23/03/06

The Briars 31/03/05

The Briars 07/01/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Briars 4 Station Road Thornton Cleveleys Lancashire FY5 5HY Lead Inspector Patrick Rooney Unannounced 30 August 2005 10:00am th 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 Briars F57 F09 S59597 The Briars V220824 180805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Briars Address 4 Station Road Thornton Cleveleys Lancashire FY5 5HY 01253 854722 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) Mrs Ellen Hewitson Mr Martin Paul Hewitson Miss Victoria Ellen Cryson CRH Care Home 15 Category(ies) of OP Old Age 15 registration, with number of places The Briars F57 F09 S59597 The Briars V220824 180805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Radiators in the home are guarded or have guaranteed low temperature surfaces by 6 July 2004. 2. The home shall at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 31st March 2005 Brief Description of the Service: Thse Briars is situated in Thornton Cleveleys near Blackpool, shops and amenities are nearby. It is a detached property offering residential care for 15 elderly persons. There are bedrooms on the ground and first floor, 13 are single rooms, two of which are ensuite. There is one double room on the ground floor. Bedrooms are pleasantly furnished, as are lounge and dining areas. A passenger lift facilitates access to the first floor. There is a large main lounge and a sun lounge/dining area. A pleasant garden area is available for the use of residents. The home has achieved the Investors in People Award. The Briars F57 F09 S59597 The Briars V220824 180805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit and took place over a period of four hours. The information contained in the report has been gathered by discussion with the owners, the manager, discussion with staff and discussion with residents and visitors. Questionnaires were distributed and completed by most residents. Completed questionnaires were also received from four relatives. Positive feedback was received from all discussions and questionnaires. Residents told the inspector that they are well cared for and that staff are caring and approachable and meet their needs. The inspector carried out a tour of the home and examined records, policies and procedures. It is of concern that a requirement made at the last inspection on 31st March 2005 has not been implemented. The inspector found that a member of staff had been employed without a Criminal Records Bureau Check or a Protection of Vulnerable Adults check. Also on checking the staff file it was found that, inadequate references had been provided by the employee. A letter requiring the manager and owners to rectify this situation immediately has been sent prior to this report. The care records of four residents were examined and the care they receive was measured against their records. What the service does well: The home is a small home and provides good personal care to residents. Residents comments regarding the care they receive are: “ They are marvellous, its beautiful here, I am in a very good lovely place, I like it very much and the food is good.” Another said “ They are fantastic, I only need to mention something and they do it”. Another said “ They are truly good they don’t just close their eyes to things.” There is good rapport with residents the inspector observed this to be the case during the inspection. The Briars F57 F09 S59597 The Briars V220824 180805 Stage 4.doc Version 1.40 Page 6 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 Briars F57 F09 S59597 The Briars V220824 180805 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 The Briars F57 F09 S59597 The Briars V220824 180805 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 and 3 Residents receive information about services the home offers. The admission and assessment procedure is clear and ensures the care needs of residents are addressed and acted upon. There is a clear contract and prospective residents are offered a trial period. EVIDENCE: The inspector looked at the homes admission procedures and looked at the files of four of the most recent admissions. All had full assessments recorded on their files including risk assessments. Residents spoken to said they were happy with the level of care and support they receive and said that there care needs are met. They also said that they received a service users guide and a contract. Assessments are signed by the resident or their representative. The Briars F57 F09 S59597 The Briars V220824 180805 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,and 10 Residents plans of care are set out in an individual care plan and show that promotion of health and welfare is taken seriously. Privacy and dignity is upheld by the home. EVIDENCE: The inspector examined four residents records, these clearly described their health needs. Residents care is clearly recorded with risk assessments in place. These are signed by the resident or their representative and are reviewed every month. Residents were spoken to and said they are happy with the care they receive. One said “ They are marvellous, its beautiful here, I am in a very good lovely place, I like it very much and the food is good.” Another said “ They are fantastic, I only need to mention something and they do it”. The Briars F57 F09 S59597 The Briars V220824 180805 Stage 4.doc Version 1.40 Page 10 Another said “ They are truly good they don’t just close their eyes to things.” All residents also said that staff carry out their duties respecting residents privacy and dignity. Questionnaires received also confirmed this to be the case. The homes policies and procedures require staff to respect the independence, privacy and dignity of residents. Staff spoken to showed an understanding of these principles. The Briars F57 F09 S59597 The Briars V220824 180805 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 and 13 Daily routines are flexible and arranged around the needs and wishes of individual residents. There are a good variety of activities arranged by the home. Residents are assisted in maintaining contact with family, friends and local community. EVIDENCE: The inspector saw a record of activities arranged for residents, these include entertainers, reminiscence, clothes parties, walks, bingo, open evenings , and parties with families. Residents confirmed that these activities are provided and that there is always something to do. Residents meetings are regularly held and everyone decides what activities are arranged. Residents said that family and friends are made welcome and are able to take them out. Cultural and religious needs are met and local clergy visit the home. Residents said both verbally and in questionnaires received that there is flexibility in how the home operates. They rise and retire when they wish and use their own rooms during the day if they wish. All were content with how the home runs from day to day. The Briars F57 F09 S59597 The Briars V220824 180805 Stage 4.doc Version 1.40 Page 12 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 Arrangements for complaints are good, the management of the home respond quickly to complaints. There is an effective whistle blowing policy, which staff are aware of and which ensures protection of residents. EVIDENCE: The home has a detailed complaints procedure, this was seen by the inspector. In discussion with residents and visitors the inspector found that they were aware of what to do if they had a complaint. They said that they found the manager and staff of the home approachable if they were concerned about anything. Information about the complaints procedure is available in the service users guide. There is also information in the home for residents to access independent advocacy if they wish. A record of internal complaints is kept and outcomes recorded. There has been one complaint made to the CSCI since the last inspection. This concerned issues regarding staff smoking and quality of food. The owners of the home investigated the complaint and provided a report to the CSCI. This complaint was not upheld. The inspector has sampled the food at the home and has seen menus. There are always choices and the quality of food is good. Residents said during the inspection that the food was good. The inspector saw evidence that the home has carried out a thorough investigation into the issues raised and has taken steps to ensure residents concerns are dealt with. The Briars F57 F09 S59597 The Briars V220824 180805 Stage 4.doc Version 1.40 Page 13 There is a procedure available to protect residents from abuse including a whistle blowing policy. Staff interviewed demonstrated an awareness and understanding of these policies. All staff on duty at the time of the inspection were interviewed separately, all felt that they could approach management if they were concerned about anything. The Briars F57 F09 S59597 The Briars V220824 180805 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, 25 and 26 The standard of furnishings and decoration are generally good and provide a homely environment, which is clean and warm. There are pleasant exterior surroundings, which residents can use in good weather. EVIDENCE: The inspector carried out a tour of the public areas of the home and saw residents in their own rooms. Standards of decoration and furnishings in the home are good and provide a comfortable homely environment for residents. Residents told the inspector they felt are happy with the standard of their accommodation. The Briars F57 F09 S59597 The Briars V220824 180805 Stage 4.doc Version 1.40 Page 15 The inspector saw a maintenance log and spoke to the handyman employed by the home. Regular checks are made around the home and any repairs are promptly dealt with. The home was observed to be clean and tidy and the inspector examined the homes procedures regarding infection control, these were In order and ensure good standards are maintained at all times. The Briars F57 F09 S59597 The Briars V220824 180805 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) 28 and 29 The home needs to ensure that the levels of trained staff are increased. Staff recruitment procedures need to be tightened up to ensure protection of residents. EVIDENCE: The inspector looked at staff training records and found that out of 13 care staff two are currently qualified to at least NVQ 2 in care. However there are currently 3 staff doing this qualification and 2 doing NVQ3. On examining the files of recently appointed staff the inspector found that there was a member of staff working in the home who had not been checked out with the Protection of Vulnerable Adults List, or a Criminal Records Bureau Clearance. The inspector found that the application for these clearances had not been sent out. This person had also not completed a full work history on the application form and references had not been sent for. There were two references that were bought by the applicant prior to starting employment. The owners must always send out for references for that particular job and must include the previous employer. This is taken very seriously as during the previous inspection a requirement was made that the owners must at all times ensure that all staff have received the necessary clearances before starting work. The Briars F57 F09 S59597 The Briars V220824 180805 Stage 4.doc Version 1.40 Page 17 Prior to this report being sent out a letter has been sent to the owners requiring them to ensure all clearances are carried out correctly prior to a new member of staff starting employment at the home. The Briars F57 F09 S59597 The Briars V220824 180805 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) 31, 32 and 37 The home is managed and run efficiently. There is leadership guidance and continuity. Staff and residents are aware of the management structure and know who to go to with any concerns. The daily recording system in use at the home can potentially breach privacy and is contrary to the requirements of the Data Protection Act 1998 EVIDENCE: The registered manager and the homes owners are in contact with the home on most days and are well known to all the residents. They ensure there is continuity and residents told the inspector they are confident that anything The Briars F57 F09 S59597 The Briars V220824 180805 Stage 4.doc Version 1.40 Page 19 they are concerned about is quickly dealt with. The registered manager has almost completed the Registered Managers award. During the inspection the inspector asked to look at the daily recording system for residents care notes. He was shown a “report book” which contained daily recordings regarding the care of individual residents written together in one book. As residents have the right to look at things written about them this would not be possible as they would be able to see items regarding other residents. This system is also in breach of the Data Protection Act 1998. The manager was advised to have a loose-leaf system in which daily recordings for residents are contained on individual records which are available to residents or their representatives. The Briars F57 F09 S59597 The Briars V220824 180805 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x 3 3 STAFFING Standard No Score 27 x 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x x 2 x The Briars F57 F09 S59597 The Briars V220824 180805 Stage 4.doc Version 1.40 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 29 Regulation 19 Requirement The manager of the home must ensure that acceptable references are obtained and that all staff are POVA and CRB cleared prior to bebining employment at the home. Timescale for action Immediate action required. 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 28 37 Good Practice Recommendations The home should have 50 of staff trained to NVQ 2 Daily recording regarding residents should be done separately to protect confidentiality and to comply with the Data Protection Act 1998 The Briars F57 F09 S59597 The Briars V220824 180805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 2nd Floor, Unit 1 Tustin Court Port Way Preston PR2 2YQ 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 Briars F57 F09 S59597 The Briars V220824 180805 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. 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