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Care Home: Bournbrook Manor

  • 134a Bournbrook Road Selly Park Birmingham West Midlands B29 7DD
  • Tel: 01214723581
  • Fax: 01214723581

Bournbrook Manor is located in a residential area of Selly Park in South Birmingham. The home is a large detached property, which offers care to nineteen elderly people. It is well situated and gives easy access to public transport and local amenities including shops, churches and park. Accommodation is offered over two floors with 15 single and 2 double bedrooms. All but one of the bedrooms have en-suite toilet and wash hand basins, two of the bedrooms also have an en-suite shower facility. The home has a shaft lift and a stair lift (although this is rarely used) giving easy access to the first floor for those with mobility difficulties. There is an assisted shower room on the first floor and a large assisted bathroom on the ground floor, which is also equipped with a shower. There are adequate toilet facilities throughout. Communal areas comprise of two large lounges and a dining room. There is parking space on the road to the front of the home. To the rear is a well-maintained garden with decking and garden furniture. The homeâs fees are between £329.96 and £405.00 for people funded by local authorities there is a top up fee. There is a charge for hairdresser and chiropody services that visit the home.Bournbrook ManorDS0000017006.V378496.R01.S.doc Version 5.2

  • Latitude: 52.439998626709
    Longitude: -1.9279999732971
  • Manager: Miss Tracey Leanne Harper
  • Price p/w: £367
  • UK
  • Total Capacity: 19
  • Type: Care home only
  • Provider: Usha Odedra,Mr Rajen Odedra
  • Ownership: Private
  • Care Home ID: 3213
Residents Needs:
Old age, not falling within any other category

Previous Inspections

This may not be the latest inspection for this service as we are having techinical problems updating from CQC - please check directly on the regulators website for the most recent report; bestcarehome hopes to be back to regular updates shortly.

For extracts, read the latest CQC inspection for Bournbrook Manor.

Key inspection report CARE HOMES FOR OLDER PEOPLE Bournbrook Manor 134a Bournbrook Road Selly Park Birmingham West Midlands B29 7DD Lead Inspector Jill Brown Key Unannounced Inspection 13th November 2009 08:35 DS0000017006.V378496.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bournbrook Manor Address 134a Bournbrook Road Selly Park Birmingham West Midlands B29 7DD 0121 472 3581 0121 472 3581 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) Mr Rajen Odedra Usha Odedra Miss Tracey Leanne Harper Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) 19 The maximum number of service users who can be accommodated is: 19 20th October 2008 Date of last inspection Brief Description of the Service: Bournbrook Manor is located in a residential area of Selly Park in South Birmingham. The home is a large detached property, which offers care to nineteen elderly people. It is well situated and gives easy access to public transport and local amenities including shops, churches and park. Accommodation is offered over two floors with 15 single and 2 double bedrooms. All but one of the bedrooms have en-suite toilet and wash hand basins, two of the bedrooms also have an en-suite shower facility. The home has a shaft lift and a stair lift (although this is rarely used) giving easy access to the first floor for those with mobility difficulties. There is an assisted shower room on the first floor and a large assisted bathroom on the ground floor, which is also equipped with a shower. There are adequate toilet facilities throughout. Communal areas comprise of two large lounges and a dining room. There is parking space on the road to the front of the home. To the rear is a well-maintained garden with decking and garden furniture. The home’s fees are between £329.96 and £405.00 for people funded by local authorities there is a top up fee. There is a charge for hairdresser and chiropody services that visit the home. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We visited the home unannounced on a day in November 2009. We completed a key inspection which means we inspected the homes performance against most of the National Minimum Standards. The home gave us information in an Annual Quality Assurance Assessment (AQAA) before the inspection. The AQAA shows how the home rates their performance in the areas set out in this report and what improvements to the service they intend to make. During the inspection we case tracked two peoples care. This means we looked at all the homes records about the person, their medication, any money held on their behalf and their bedrooms. We looked around parts of the building. We also looked at other records about the safety of the building, complaints accidents and so on. We sent out surveys and received 2 back from people that live in the home, 2 from relatives, 1 from a health care professional and 10 from staff. We spoke to 5 people living in the home, 3 relatives, 2 staff and the manager. We have received no complaints about this service. What the service does well: People and relatives are offered the chance to visit the home before admission. The homes AQAA states We encourage all prospective service users to come and have a day visit with us...We always encourage relatives to look around the home at a suitable time for them we do not book appointments... This allows people and their families to see the home at differing times of day to determine if it is suitable. People had care plans and risk management plans in place very soon after admission and this means staff have the information they need to give good care. The home works well with health and social care professionals they commented no issues very impressed with my persons view of the home. Wonderful home, high standards of care and professionalism. They monitor Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.2 Page 6 the patients and if they have any concerns will contact us for advice and support. As a team of nurses the staff treat us as well.....(they) act upon our advice. People were happy with the care they received people said:They pop in and check on me throughout the day. I am no longer worried or sad about coming back here when I have been away with family. It now feels like family. I am very happy Everything is much better. girls are nice and work hard. The home works well with relatives they said: The service does most aspects (of care) well. They support me to help with the needs of my relative at her age. I feel (my relative) is loved and respected. There is a very open door policy here. They keep in touch with you when your relative is in hospital. Relatives feel welcome. The home was clean fresh and well ordered on the day of the inspection. The home has sufficient, trained and experienced staff to provide good care for people. Peoples money is accounted for with audits of records and receipts. There are monthly visits to the home on behalf of the provider and reports of these visits are written. These show that people living in the home and staff have been spoken with and quality checks of the service provided. Health and safety checks are undertaken and this means that people have a safe environment. What has improved since the last inspection? Before coming into the home people have information about their needs collected. This information now includes an assessment about whether the persons liberty is an issue and this helps to preserve peoples best interests. Further information is collected about the person when they arrive in the home about their preferences in how their care is delivered and this helps to ensure the service suits them. The administration of mediation has improved and maintained improvement from the inspection in December 2008. Copies of prescriptions are checked against information received on the Medication Administration Record (MAR) and this ensures the right medication has been dispensed. The homes record of complaints has improved and we found no concerns that had been raised that had not been logged. The home has put in place a comment book in the reception area. All comments were good and there are a number of them contained in this report. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.2 Page 7 We found where people needed regular checks to prevent pressure sores or to ensure that peoples food and fluid intake was sufficient the home kept good records. This allows the home and health professionals determine if peoples health is getting worse. We found where there was an incident the management learned by it and put in place measures to lessen the chances of such an incident reoccurring. Staffing levels have improved with an extra member of care staff being available on an early shift and a cleaner being available Monday to Friday. We received comments from staff and relatives on the improvement this has made. The manager of the home is able to dedicate all hours worked to management tasks and this has ensured the improvements needed to records and the quality of service delivered to people. What they could do better: Although care records are more clear more information is needed on diagnosed health conditions to ensure that staff have information about signs and symptoms that would indicate the person is becoming unwell. Information about medication allergies must be consistently recorded and especially transferred on to the MAR charts. This is to ensure people have medication that is safe for them. Although the service has improved the range of activities were not wide enough to meet people and their representatives expectations. They said There needs to a wider range of activities available. There needs to be a more varied range of activities, with more treats and visits outside the home. Have more activities as there is too much TV. We found that peoples interactions with staff were good but there was little individual planning of activities meaning that not all people had activities they were interested in or reflected their past experience. Food tended to be traditionally English and may not reflect peoples wider experiences of food. We found that the assistance provided at meal times needed to be reviewed to look at specialist equipment, the number of people requiring assistance and the space provided. A person said They need a better choice of menu not just basic foods. Although there were appropriate checks to ensure that staff were safe to work in the home it is strongly advised that the manager checks with the appropriate authorities the maximum number of hours specific staff can work. The manager has yet to attend the recommended Leadership and Management course. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.2 Page 8 We were not aware of a number of incidents and accidents in the home and copies of notifications for some these were not available. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 9 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 Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3,5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Enough information is collected about peoples needs to decide whether these needs can be met within the home. People and their representatives have the opportunity to visit the home before admission and this helps them decide whether the home will suit them. EVIDENCE: We looked at the information collected about two people before they were admitted. We found that both people had information collected about their physical and mental health abilities and medication. These abilities were rated from good to poor on a scale rating and a judgement made about how many staff may be needed to assist the person. Additional information was collected from the placing social workers care plans. However, one of which was dated following the persons admission. These details help the home develop a plan of care to meet peoples health and personal care needs. The home has also Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 11 developed a form which considers whether the person is in agreement with coming into a home or whether their liberty is being deprived. This helps to ensure peoples best interest is being considered. On the day of admission a personal profile is completed this includes information about the persons history such as their family, work, relationships and what they used to like to do. It also includes information about their cultural and religious background. These details help the home plan peoples care in a way that respects their lifestyle and interests. People are offered time in the home before they are admitted. The homes Annual Quality Assurance (AQAA) stated We encourage all prospective service user to come and have a day visit with us...We always encourage relatives to look around the home at a suitable time for them we do not book appointments... This allows people and their families to see the home at differing times of day to determine if it is suitable. Where people choose not to visit this is recorded and one such record stated if (my) niece likes it I will. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that the home can provide and meet their needs in a way that promotes their health, well being and safety. People have their medication given appropriately and this helps to ensure their good health. EVIDENCE: We looked at the care plans and risk assessments for two people and found that these had improved. Care plans and risk assessments were written in timely way following admission and this means that staff have the information they need to give good personal care quickly. Care plans give descriptions of how care staff can assist the person to make choices and respond to how the person likes their care to be given. For one person this included stating the person was able to say what they liked and disliked in care, food and times to get up and so on. It also pointed out how the staff could support the person Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 13 such as forgetful at times and then worries staff to reassure when this happens. We checked information in the care plan for a person which stated when they were in the room their call alarm was to be near them and that they should have access to their walking frame. These were in place and we talked to the person who told us how they use them. Care plans did not have enough information about health conditions. For one person there was no information about their hernia and asthma, for another mental health issues. This information ensures that staff are aware of any signs and symptoms that may show people are not well. However practically there has been good improvement in the monitoring of people with high health needs for people that need turning and their food monitoring appropriate charts are in place and these are completed well. Information from health professionals is taken into account; a person had instructions exercises provided by the physiotherapist in their room and these were followed. A health professional said They monitor the patients and if they have any concerns will contact us for advice and support. As a team of nurses the staff treat us as well.....(they) act upon our advice. A relative told us we owe the home debt of gratitude they agreed to have (my relative) back although they know that she would be now assessed as requiring a nursing home but they are working closely with the district nurses. They said this is her home. Risk assessments were available and for one person these included individual safety issues of the person having a mat they wanted in their room. Another had a risk assessment about the bedroom door being open and a door guard being in place which would close if there were a fire. People have moving and handling risk assessments. We observed a number of people being moved from place to place by a hoist and found that these moves were undertaken well. Staff talked to the person and did not move the person until they were ready to be moved. Information about the equipment needed to move the person was kept with the appropriate hoist and people that needed hoisting had their own slings. This helps to ensure good infection control and appropriate lifting of people. We also observed that the pressure relieving cushion for one person was moved from the wheelchair to the chair so as to ensure that the person was at less risk of gaining pressure areas. People were dressed appropriately, women had clothing that matched and was in good condition and where men wanted, they were assisted to wear ties and people were helped to maintain the style of dress they were used to. Care plans provided this information. Peoples hygiene needs were observed to be met. Social care professionals commented no issues very impressed with (my persons) view of the home. wonderful home high standards of care and professionalism. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 14 We observed interactions between staff and people that have some memory difficulties. We found that staff assisted these people well. One person was able to accept having a meal at the home despite refusing initially because they hadnt paid, another was assisted to interact with other people and deflected from walking continually. We looked at the medication administration for three people and found that the improvement from the last inspection had been maintained. The medication is stored securely in a medication trolley. There are first aid boxes on each floor of the home and this useful in case of emergencies. Copies of the current prescription are kept and this helps to ensure that the medication dispensed from the chemist is as prescribed. In front of the medication administration records (MAR) there is a photograph of the person and this is an extra check to ensure the right medication is given to the right person. There was nobody self administering medications at the time of the inspection. One person had allergies to medication and this was not written on the MAR, this was rectified at the time of the inspection. We did see a risk assessment for allergies to medication but practice was not consistent and this could result in a person being given medication that did not suit them. Medication audits were being undertaken without notice and were also part of the checks that were done on behalf of the owner. The MAR were in good order with staff signing the sheets after medication had been given and counts of medication matched the record. People were observed to be talked to in a respectful manner. One person told us girls are nice and work hard. Another told us I am no longer worried or sad about coming back here when I have been away with family. It now feels like family. I am very happy Everything is much better. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot be fully assured that the home is able to meet their needs and choices of activities and meals and these enhance peoples lives. People are helped to maintain relationships with relatives and representatives. EVIDENCE: People in the home do not have an individual activity plan and this may ensure that people have more relevant activities. The homes AQAA indicated that staff training in this area is needed. Details are recorded about peoples previous interests and activities but this did not necessarily match the activities that were offered in the home. People were not encouraged to maintain skills such as housekeeping that they may have had previously. Records showed us that people have the opportunity to be involved in talking with students from the local university and school, playing board games, be involved in chair exercises, doing some craft work and watching the TV. A number of students were in the home at the time of the inspection. We saw some displayed craft work on a wall in the home. Some people prefer staying in their rooms watching TV or reading. The homes AQAA told us that they have an event once a month. The records showed that a minister attended the home to offer Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 16 a religious service for those people who wanted this. A person told us there needs to a wider range of activities available. Two relatives surveys told us:There needs to be a more varied range of activities, with more treats and visits outside the home. Have more activities as there is too much TV. Staff surveys also indicated that more outings should be offered. We were told by one relative that there is to be a Friends of Bournbrook Manor set up and they will be looking at what activities could be available to people at on an evening. We spoke to three relatives, received surveys from two relatives and noted some compliments in the home comment book. They said the service does most aspects (of care) well. They support me to help with the needs of my relative at her age. I feel (my relative) is loved and respected. There is a very open door policy here. They keep in touch with you when your relative is in hospital. Relatives feel welcome. People were able to walk about the home if they wished. There was a locked door at the front of the home but this was to ensure the safety of people from the road. People could choose where to have their care delivered and where they wished to eat. We looked at the menus provided by the home and joined people as they ate the main meal of the day in the dining room. The dining room itself is small and cannot accommodate all the people if they chose to eat together, although there is another table in the large lounge. Space is made more difficult by the number of people that use wheelchairs. The dining experience for people was generally calm. People were given a choice of meals and this was supplied already plated. Already plated meals can stop some of the social interactions at meal times however one person living in the home was helping other people by encouraging them to eat. There were table cloths cutlery, glasses and drinks and condiments available on the tables. There were a number of people that needed assistance to eat. The number of staff available and the space meant that one staff member stood whilst assisting more than one person which does not allow the individual attention needed. Another staff member was able to sit whilst assisting another. There was evidence of some equipment such as large handled cutlery being available but one person observed could also benefit from this, this helps people remain independent. One person had difficulty seeing the food and consideration should be given of different coloured plates to enable the contrast of food to be more easily seen. The menus provided showed that people were able to have a hot food option at all three main meals. One person told us that they liked to have a cooked breakfast and were not really bothered about the lunch time meal. The menu was mainly traditional English food and on the day of the inspection people had the choice of cooked ham or fish. We discussed with the manager the increasing variety of foods people have experience of before coming into a care Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 17 home. Surveys told us There needs to be a better choice of menu and not just basic foods. People were observed to be offered and encouraged to drink throughout the day and this helps to prevent people from becoming dehydrated. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home can be assured that their concerns are being listened to and acted upon. The home has appropriate policies and procedures to ensure peoples safety. EVIDENCE: The home has a complaint procedure available and this is available in a picture format. There is also a book at the front of the home for people that have visited to comment on the service they have received. The comments were all positive and are reflected through this report. The homes AQAA told us that the home had had 1 complaint and 2 were logged one being logged following the AQAA being sent. These had been investigated and steps had been put into place to rectify the situation. People surveyed said they knew how to make complaints. We havent received complaints about this service. We havent received information that required the safeguarding procedures to be used. The home has safeguarding and whistle-blowing procedures available if these are needed. These procedures have been reviewed this year. The manager and some staff have received training in the Mental Capacity Act and this helps to ensure that peoples rights and best interests are maintained. Staff coming to work at the home have appropriate checks before they start work and this helps to keep people safe. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment of the home provides a safe and comfortable place for people to live. EVIDENCE: The home was generally well maintained clean, fresh and tidy on the tidy throughout the day of the inspection. The Food Safety Department had given the home an excellent rating for the kitchen earlier in 2009 and Health and Safety had also visited and had made 4 recommendations. The home had complied with these recommendations at the point of our inspection. People have two lounges, which they can use during the day if they wish. There is a passenger lift available from the ground to the first floor. The layout of the building generally meets the needs of the people living there however Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 20 the dining area is not large enough should all of the people resident wish to use it. Peoples rooms that were looked at were clean and there was evidence of personal belongings such as photos, books, televisions and so on and these help people to feel comfortable in their rooms. There was evidence of special equipment such as crash mats, commodes and walking frames where these are needed and these help to ensure that peoples personal care needs are met safely. There was some signage such as a sign for communal toilet to help people with memory difficulties remember where key places were. Areas which were unsafe for people to be unsupervised had locks on such as the laundry. The laundry had appropriate washing and drying facilities to meet the people in the home. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this have the benefit of committed staff in such numbers experience and training to give good care. EVIDENCE: The usual staffing level for the home is a senior carer and 3 carers, a cook and a domestic are on duty in the morning until 3pm during the week. On the weekend there is a senior carer and 3 carers and a cook but no cleaner. In the afternoons there is a senior carer and 2 carers. At night there are 2 night staff with the manager and deputy sharing on call. The manager hours are in addition to this and she usually works during the week. Rotas indicated that this level of staffing is usually kept to. The staffing level had been increased since the last inspection. We found the following comments It is much better having an extra carer on duty in the morning and the cleaner makes a big difference. Cleaner very friendly and its spotless after they have cleaned, staff are very helpful. The staff are very nice and caring. A number of the staff have worked in the home for a long time and a number of people were concerned about some of the established staff leaving. The homes Annual Quality Assurance Assessment (AQAA) told us that 90 per cent of staff have attained a National Vocational Qualification level 2 in care Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 22 and this is the qualification we recognise as important for care staff to deliver care well. We looked at the recruitment information on 2 new staff. One staff member was recruited by the home and we found that a robust recruitment process had been followed. The person completed an application form, was interviewed, references were obtained and required checks with the Criminal Records Bureau made before the person was employed. There were copies of their training certificates of courses undertaken before they started with the home. This process safeguards people living in the home. The other staff member had been recruited by a training college. The home was supplied information about the checks the college had undertaken. It was noted the person was on a student visa and was working full time on placement we advised the manager to confirm with the authorities what restrictions there were on the hours of work. The homes AQAA told us that staff at the home received training. We spoke to 2 staff who told us that they had received all mandatory training over the last 12 months. We received 10 staff surveys all of whom told us that they received relevant training that helped them understand the needs of individual people and keeps them up to date with new ways of working. These surveys indicated that staff were proud of the service they delivered and were committed to ensuring people had a good service. We saw evidence that a half day dementia awareness course had been planned. The AQAA also told us that people had training in eye care and bereavement in the last 12 months. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37 &38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall people live in a well managed home where their safety is assured and promoted. EVIDENCE: The manager of the home is registered with us and this means that can be held accountable in part for the service provides. The manager has yet to complete a Leadership and Management course that is recognised by us. The manager and deputy manager have many years experience working in care homes for older people. Staff working in the home are positive about the management of the home one staff member commented we have wonderful support from our manager and deputy. One person living in the home said Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 24 The manager and deputy manager are both very caring and considerate always willing to listen and try to solve any problems. Requirements from previous inspections have been acted upon and there is a clearer monitoring of peoples health and wellbeing. The manager had completed the Annual Quality Assurance document well and this was an improvement on the previous year. The information contained has generally been found correct on inspection. The service has a monthly visit from a representative of the providers and a report is written on their findings and recommendations are made on how the service can improve. These reports indicate that people living in the home and staff have been spoken to as part of the home judging their performance. There were no people living in the home that were subject to a deprivation of liberty authorisation under the Mental Capacity Act at the time of the inspection. No person has had a best interest assessment and we did not see a situation where this was needed. The manager has had training on this and has stated that a number of staff have. Information about the mental capacity act and deprivation of liberty was available. The manager undertakes initial assessments of people before admission and has added documents to ensure that it takes account of this legislation. We looked at a sample of money that was held on behalf of people living in the home and found that the money held matched the record. Receipts were kept for any service or goods that the home purchased on behalf of a person. Peoples money is usually brought in by family and was usually spent on services such as hairdressing and chiropody. Peoples money was checked on a weekly basis to ensure it was correct. We looked at a number of health and safety records for gas, fire, water and lifting equipment safety and found that these services were maintained and inspected as required. This helps to ensure peoples safety within the home. We looked at the homes accident records. Where people fall repeatedly the home refer the person to look for causes. Where an accident has happened the home showed they have reviewed the situation and put measures in place to ensure that the chances of this happening again is minimised. The home did not have a copy of all the notifications they should have sent to us and we have not received some. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 25 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 3 Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 26 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 OP9 Regulation 13(2) Requirement Where people have an allergy to medication this must be written on the MAR. This is to help ensure that the wrong medication is not prescribed and to inform the hospital if the person is admitted. Timescale for action 28/12/09 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 OP1 Good Practice Recommendations The statement purpose must be reviewed to ensure that it contains accurate information about the service. Not inspected on this occasion Where people have a diagnosed physical or mental health condition a plan should be written to show any considerations that are needed in the persons care and any signs or symptoms that would indicate that the persons health was deteriorating. A range of activities must be provided to meet the needs of all the people in the care home. DS0000017006.V378496.R01.S.doc Version 5.3 Page 27 2 OP8 3. OP12 Bournbrook Manor Not met on this occasion 4 OP15 A review of meals and mealtimes should be undertaken to demonstrate that: People have influenced the menu provided and larger range of options suggested. How a good level of assistance to people can be managed at meal times. How people can be supported to more independent including any arrangements to minimise the effects of sight loss and other physical impairments. It is strongly advised that the appropriate authorities are approached to determine the maximum number of hours staff on a student visa can work. The manager must complete the Registered Managers Award or equivalent. Outstanding since the June 2006 Copies of Reg 37 notifications should be kept. The commission should be notified on any incident outlined in the guidance. 5 6 OP29 OP31 7 OP38 Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 28 Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Bournbrook Manor DS0000017006.V378496.R01.S.doc Version 5.3 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!

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