Inspection on 20/06/05 for Brendoncare Old Parsonage

This inspection was carried out on 20th June 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 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

Brendoncare Old Parsonage 06/01/09

Brendoncare Old Parsonage 09/01/07

Brendoncare Old Parsonage 31/01/06

Brendoncare Old Parsonage 07/12/04

Brendoncare Old Parsonage 06/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Old Parsonage Brendoncare Home Main Road Otterbourne Winchester Hampshire Lead Inspector Anita Tengnah Unannounced 20/6/05 10:00am 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 Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Old Parsonage Brendoncare Home Address Main Road, Otterbourne, Winchester, Hampshire, S021 2EE 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) 01962 713977 01962 715866 The Brendoncare Foundation Sally Elizabeth Frame CRH 31 Category(ies) of OP: Old Age- 31 registration, with number of places The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7/12/2004 Brief Description of the Service: The old Parsonage is a registered care home providing personal care and nursing for 31 service users in the older person category. The Brendoncare foundation owns the service and has a sister home in the Hampshire area. Accommodation is provided on two floors and there is a passenger lift that allows access to all parts of the service. There is a number of equipment and adaptation within the home to maintain and promote independence of service users accommodated. The home benefits from well maintained enclosed gardens and accessible to wheelchair users. The service is situated in the village of otterbourne on the outskirt of Winchester and has some local amenities close by. The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was undertaken over one day on the 20th of June 2005. As part of the inspection process, a tour of the building was undertaken. The inspection took place over 5 hours. The inspector spoke to 15 service users, 8 staff and the manager. The process included examining care records, medication records and discussions with service users, visitors and staff. What the service does well: What has improved since the last inspection? The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 6 The ground floor bathroom facility has been completely refurbished and has been fitted with an adjustable assisted bath. This was found to be homely and appropriate to service users needs. Service users spoken to also commented on the facilities and the homely environment that the service offers. The hairdressing room has also been refurbished. Service users spoken to said that it was like going out to the hairdresser outside and enjoyed having their hair done regularly. This area was accessible to wheelchair users and a toilet facility was available. The inspector was advised that a grab rail would be fitted in the communal toilet area. Service users commented on the nice dining room that has been recently refurbished and new dining chairs were in place. 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 Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.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 Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.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) 3 The home has a good process of assessment prior to admission to ensure that service users needs are met. EVIDENCE: The manager assesses all service users prior to admission to the home. Family visit, as often service users are too frail to attend the home prior to admission. Information as per the statement of purpose is available to service users and also copy of the previous inspection as requested. The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 There is a satisfactory system of care planning in place, this provides staff with the information they require to meet the needs of service users. The lack of review of some care plans and manual handling assessments can be detrimental to service users welfare. The staff have good understanding of service users’ support needs. This is evident from the positive comments from the residents. The lack of recording with regards to prescribed medication is detrimental to the welfare of service users. EVIDENCE: Arrangements were in place to meet the assessed needs of service users. Care plans were formulated and included risk assessments and manual handling assessments. There was evidence that care plans were formulated with the involvement of service users or their families. Not all of the care plans seen were updated and this was discussed with the manager that all care plans must be reviewed to reflect any changes in the needs of service users. The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 10 Service users and relatives spoken to were complimentary with regards to the care that they were receiving. Service users stated that staff were very kind, they spoke proudly of their bedrooms and that they could receive visitors at any time. Four service users spoken to state that they had autonomy and choice with regards to the activity of daily living. They chose when they went to bed and whether to remain in their rooms or join others in the conservatory Equipment for the prevention and treatment of pressure ulcers were available in conjunction with Waterlow score that calculated the risks. Wound care plans were in place, advice is sought from other healthcare professionals such as tissue viability nurse as required. Wound care plans required further development to include wound grading and types of dressing. This was discussed with the nurse in charge and instructions regarding treatment/ change of dressing must be clearly recorded to inform practice. There were detailed and up to date records of visits from the GP and any changes in treatment were clearly recorded to inform practice. The GP holds weekly surgery at the home and is available at other times. Service users and relatives spoken to were complimentary with regards to the care that they were receiving. Service users stated that staff were very kind, they spoke proudly of their bedrooms and that they could receive visitors at any time. Five service users spoken to stated that they had autonomy and choice with regards to the activity of daily living. They chose when they went to bed and whether to remain in their rooms or join others in the lounge. Comments from service users spoken to include “I could not fault it If I wanted”. “The staff are always there to help. “ The girls are very nice and do their best”. The meals are always very good and we can have wine if we want. “The chef is lovely and does a very good job”. The home has a policy and procedure for the management of medication. The manager reported that the home was in the process of introducing a new system of medication management and was confident that this will have a positive impact. This will include a record of drugs received and returned on the medication Administration Record (MAR) sheet. Training in medication was available and had been completed by a number of staff. All medication was stored securely and controlled drug was administered as per set procedure. It was noted that on a number of occasions medications were not signed for on the MAR sheet. This can be detrimental to the welfare of service users. This was discussed with the nurse in charge and remedial actions such as appropriate coding for reasons of non- administration/ missed dosages need to be in place. The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 11 The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.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) 13,15 The home’s open visiting policy supports the choice and wishes of service users. Meals at the home is very well managed offering choice and variety to service users. EVIDENCE: The home has an open visiting policy. A record of all visitors to the home was available. Service users spoken to stated that there was no restriction on visiting times and they have the choice of seeing their friends/ relatives in private or in the various communal areas at the service. Daily newspapers were available and delivered to the home. The home has a planned menu. Nine service users were spoken to with regards to meals and they all commented that meals were very good and choices are offered. They said that the chef is always seeking their views on the type of meals that they would like and meals were always very good. Record of meal showed that there are 3 choices of main meal at lunchtime and 2 at teatime. Meals were nicely presented and appeared nutritious and well balanced. Lunchtime meals were taken in the nicely refurbished dining room and a number of residents from the close care service in the ground also attended the home for meals. Service users reported that they enjoyed the The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 13 daily visits and have made good friends with these residents. Staff were available to offer support with meals in a sensitive manner. Service users reported that they had a menu provided where they chose their meals and retained a copy for their use. It was noted that some food items were kept in the fridge on the floor. The staff must ensure that dates of opening are recorded ensuring that food items are consumed safely. The manager was addressing this and plain labels will be provided. The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has a satisfactory complaint procedure in place and service users feel able to raise their concerns as required. Training and procedures are in place and information is available for the protection of service users. EVIDENCE: The home has a complaint policy and procedure in place. Service users spoken to confirmed that they would approach the manager or the person in charge if they had any concerns. A complaint log was maintained. Record shows that there has been no complaint since the last inspection. There is a procedure in place that gave information to staff regarding reporting and recording all allegations of abuse. Training in adult protection was available. A whistle blowing policy was also in place. The manager is aware of the needs to report and refer all allegations of abuse to the appropriate authority for the protection of service users. The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 15 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, 23. The standard of décor and the furnishing were good with evidence of future planning. The home presented a warm and homely environment that provided service users with an attractive place to live in. EVIDENCE: The home has an ongoing refurbishment programme in place. A tour of the building was undertaken as part of the inspection process. The inspector found that all part of the home was well maintained and there was no adverse odour. The home had standard of décor and furnishing were in good state of repair and appropriate to meet the needs of service users. Equipments such as hoists and grab rails were sited around the home and a chair lift was also in place to promote and maintain service users independence. Part of the ongoing refurbishment included the renovation of the hair- dressing salon. Service users spoken to commented on this very good facility and one said” It was just like going to the hairdresser” The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 16 The ground floor bathroom that has been redecorated and an assisted bath was in place. Service users and staff all commented on the new bathroom in a positive light. The home has an in house laundry and all service users laundry were undertaken internally. The inspector found that the laundry was very well managed and infection control procedures were in place. The clean and soiled areas were well managed, hence promoting good infection control. The washing machines were fitted with sluice facilities; the floor was impermeable and hand- washing facility was prominently sighted. The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 17 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) 27,30 The staff have good understanding of service users support needs, this was evident from relationships that have been developed. The home has a training plan and support staff in maintaining their skills. EVIDENCE: The home has a duty rota and a separate one for ancillary staff. The home has a group of staff that have worked therefore a long time and this was recognised by service users spoken to. They commented that staff were kind and call bells were answered promptly. Staff reported that they have developed good relationship with each other and with service users. Staff stated that they were supported in their duty especially, as they had a period of instability previously. The home own staff cover any shortfall in staffing and also agency staff are used to support the home. The home has a training plan in place and recent training included all trained nurses undertaking a safe handling of medication course. Training in National Vocational Qualification (NVQ) for carers was ongoing. Seven carers are due to complete NVQ 2 in July. The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 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) 37,38 The process of record keeping is safe and protects the welfare of service users. The ongoing review and safe maintenance of equipment ensure that service users are not at risks. EVIDENCE: The inspector found that all records were maintained securely and reports with regards to regulation 37 are sent to the Commission as required. A sample of fire equipment examined showed that these are maintained at regular intervals. It was noted that the room where medication was kept was very warm as the fan was out of order. This was discussed with the manager and remedial action is required to ensure that medication is maintained at the correct temperature. The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 19 Alternative areas for equipment should be investigated to ensure that the bathroom area on the ground floor retains a homely appearance and allows access to service users. The sluice facility also need replacing in order to promote good infection control procedures and allows for the safe disposal of commodes and their cleaning. The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.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 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x 3 x x 3 STAFFING Standard No Score 27 3 28 x 29 x 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 x x x x x x 3 3 The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15(2) (b) Requirement The manager must ensure that care plans and risk assessments are updated and reviewed on a regular basis to reflect the changing needs of service users. The manager must ensure that staff maintain a record of all medication administered to service users. Timescale for action 30/07/05 2. 9 17(1) (a) schedule 3 (i) 30/07/05 3. 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 38 Good Practice Recommendations The provider should ensure that sluicing facility is available to meet the needs of service users and support good infection control procedures. The Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 Page 22 Commission for Social Care Inspection 4th Floor-Overline House Blechynden Terrace Southampton Hampshire 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 Old Parsonage Brendoncare Home H54 S12226 The Old Parsonage V232643 200605.doc Version 1.30 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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