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«Care Standards Act 2000 Inspection Report Bryncelyn Care Home Maesteg Park Maesteg CF34 9LR Type of Inspection – Baseline Dates of inspection – ...»

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Care and Social Services Inspectorate Wales

Care Standards Act 2000

Inspection Report

Bryncelyn Care Home

Maesteg Park


CF34 9LR

Type of Inspection – Baseline

Dates of inspection – 4th December 2012

Date of publication – 22 February 2013

You may reproduce this report in its entirety. You may not reproduce it in part or in any

abridged form and may only quote from it with the consent in writing of Welsh Ministers

Please contact CSSIW National Office for further information Tel: 0300 062 8800 Email: cssiw@wales.gsi.gov.uk www.cssiw.org.uk Version 1.1 07/2012 Summary About the service Bryncelyn Care Home provides nursing care for up to fifty-six (56) older people. It is a purpose built home, situated in an estate of houses on the hill above Maesteg, a small town in the Bridgend valley. The home is owned by Hallmark Care Homes (Maesteg) Ltd, and the Responsible Individual is Avnish Goyal. The manager of the home is Maria Cahalane who is currently being registered by us (CSSIW) following completion of her registration with the Care Council for Wales.

What type of inspection was carried out?

A baseline inspection was carried out on this occasion as prior to and up to the time of the inspection, the manager had not registered with the Care Council for Wales (CCfW) for a protracted period of time. Subsequent to the inspection, she completed this requirement and can now be registered with CSSIW.

We examined the Self Assessment of Service Statement (SASS) and the Service Data form (SDF) which are statutory documents completed by each service. We asked to see the available Statement of Purpose and were informed by the manager that a new Statement of Purpose was currently under review and would be available in the near future. We also examined a selection of policies and procedures. We spoke with people who used the service, their relatives, and a number of staff both qualified and unqualified.

We examined a range of documentation including risk assessments, care plans and daily records. We inspected the lounges, dining rooms, a selection of bedrooms and the laundry. The kitchen was not a main focus of our inspection as it had achieved the maximum score from the Environmental Health Inspector during the summer.

What does the service do well?

The home employs both a full time and a part time activities organiser. Activities are highly profiled in the home and there was evidence that the organisers offer a good variety of events, taking into account the preferences of the individuals using the service.

What has improved since the last inspection?

No issues of non compliance were identified at the last inspection What needs to be done to improve the service?

No issues of non-compliance were noted at the last inspection. However we notified the

manager that:

Supervision should be carried out every two months An annual quality assurance report must be made available for the public to read.

–  –  –

Quality of life Overall, we found that the quality of life experienced by the people using the service appeared to be of a high standard. This was because the home was warm, clean, and lounges and dining rooms/areas conducive to conversation. People spoken with were complimentary about the service and this indicated a high level of satisfaction with the people living there.

We spoke with seven (7) people who used the service and were willing to comment on their experience. We spoke with one group just after lunch who had all remained at their dinner table. They were eagerly anticipating the Christmas show that was being held that afternoon in the main lounge. One person stated that “This is a lovely home, it has a good reputation in the community. There’s always lots to do, I love the afternoons, and today I am really looking forward to the Christmas show”. Another commented that the “…care is wonderful…”, “…the staff are lovely…”. The general consensus was that they all felt cared for, listened to, and enjoyed good activities in very pleasant surroundings. All indicated that they had “lovely rooms”.

We observed that the standard of the food served was high. We saw evidence of choice, special diets and assistance given where needed. The staff members giving assistance to those who needed help were subtle, gentle and showed respect to the people receiving their assistance. We noted that portions were generous and well presented. It was clear that the people using the service had input to their choice of menu on a daily basis.

The available activities were wide ranging, and it was clear that a great deal of thought and planning had been employed by the two activity co-ordinators who appeared to be enthusiastic and committed. We observed activities in progress and noted the enjoyment and animation of the participants. The lounge was almost full of the people using the service and the ones who did not participate were not coerced to join in, it was their choice to remain in their rooms, or to quietly read or watch television. This meant that people using the service were stimulated, engaged and always had something to look forward to, either outside entertainment or in-house.

We spoke with eleven (11) relatives of people who used the service, and generally, they were complimentary. Some relatives indicated that although they felt that communication could be improved in some areas, they were mostly pleased with the service. Others commented that they would never be able to thank the staff enough for all they had done, and another set of relatives indicated that their relative was settled and happy, and loved their bedroom. All were satisfied with the rooms, environment and management of the care home. All indicated that they were highly satisfied with the care given and the quality of the staff group. The outcome for the people using the service and their relatives was that they were confident in the care given and with the staff who provided the care.

–  –  –

fall charts, and nutritional needs charts. Each individual had a pre-admission assessment record, admission details, and individual risk assessments and care plans.

Daily records were completed.

The medication system was a robust measured dosage system supplied by a local pharmacy, and medication administration charts had photographs of each individual to reduce the risk of erroneous dispensing.

A named nurse/carer system was in place which meant that each individual received most of their care from a dedicated source, reducing the possibility that appointments were missed, or personal preferences for care were largely unknown.

The people using the service could be confident that they were being cared for in a warm, clean environment, with plenty of activities, and the systems in place, such as nutritional needs and preferences, personal care, and medication administration were geared towards their safety and wellbeing.

–  –  –

Quality of staffing The people using the service could be confident that staff within the company had been carefully recruited and all held enhanced checks by the Criminal Records Bureau (CRB).

The staff turnover at the home was very low, and staff appeared to be happy and content in their roles.

We examined the records of two (2) qualified nurse staff members and seven (7) care workers. We found that both nurses had current Personal Identification Numbers (PIN), and a flagging system was in place to remind them of renewal for both the PIN and CRB at the appropriate time. This system was also used for work permits where applicable ad passports. We saw evidence of training for the nurses which was current and relevant to their positions and roles. Both nurses had contracts and evidence of induction.

The care workers records all had contracts of employment, evidence of induction, and recent training in all mandatory topics such as moving and handling, basic food hygiene, First Aid, health and safety, and safeguarding of vulnerable adults. In addition there was evidence of specialist training in such topics as dementia, bed rail safety, and deprivation of liberty safeguards. A training matrix was in place which ensured that training was carried out on a rolling programme at the appropriate time. However, we notified the manager that supervision was not up to date and should be addressed at the earliest opportunity. This may be a focus for future inspections.

Staff spoken with during the inspection all indicated their satisfaction with their conditions, the working environment and the manager, generally. Some indicated that the “upper management” tiers were not frequent visitors and the staff felt that they would have liked more presence from this group in the home so that they could discuss issues.

The people using the service expressed great satisfaction with the staff describing them as “…wonderful…”, “excellent…” “…the most caring people I have ever met…”.

–  –  –

Quality of leadership and management The manager had been in post for two years and although she had recently qualified in Leadership and Management, had not registered with the Care Council for Wales, which was a requirement prior to becoming registered with CSSIW. Subsequent to the inspection she became registered with the Care Council for Wales and an updated certificate will be sent from CSSIW to reflect this.

The home appeared to be well managed, although the Statement of Purpose and the policies and procedures had some anomalies. English guidelines and legislation were referred to in these documents despite the fact that there were differences between the English and Welsh Regulations. The manager indicated that she would address this at the earliest opportunity and stated that both the Statement of Purpose and the policies were in the process of being updated corporately.

We saw evidence that equipment was serviced and electrical checks had been carried out on a regular basis.

The manager had an open door policy which was appreciated by staff, people using the service and their relatives. Staff expressed their satisfaction with the support received, and people who used the service and their relatives with whom we spoke mostly indicated that they felt that their queries and issues were addressed in a timely manner.

We did not see evidence on the day of an annual quality assurance report which should be available and accessible for the public to read. However, the manager stated that quality assurance was carried out, giving the example of setting up tea and coffee ‘stations’ so that people could access refreshments at anytime, and taking away the tea trolley ‘round’. Following questionnaires, the tea trolley was re-instated as people did not want the stations, preferring the trolley. The report should be made available at the earliest opportunity to be displayed with the previous inspection report.

–  –  –

Quality of environment People using the service were cared for in a clean, warm environment, with pleasant surroundings and a good choice of seating areas. It was evident that this contributed to the obviously relaxed ambience of the home.

The home consisted of two floors with lounges and dining rooms on both floors. The lounges were well decorated and had a pleasant layout, encouraging discussion and contact with other people who used the service, with room for friends and relatives. The downstairs dining room was set out in tables of four, and appeared to be a popular meeting point. The upstairs dining room was much smaller and appeared to be little used, but was pleasant should anyone want to sit quietly to eat their food.

The standard of the furnishings was very good in the main, and there was a rolling decorating and refurbishment programme in place. This meant that people using the service enjoyed living in freshly decorated areas throughout the home, and enjoyed a high standard of accommodation.

We visited several of the rooms of the people using the service and spoke at length with some who preferred to stay in their rooms. All indicated that they found their room to be pleasant, and we noted that each room contained possessions such as photographs, paintings, ornaments, and favourite pieces of furniture in some instances.

The kitchen was well appointed and had received a score of 5, the highest score possible from the Environmental Health Officer who had visited in the summer. We did not inspect the kitchen on this occasion, but it may be a focus for future inspections.

The laundry was satisfactory, and there were dedicated laundry staff. Domestic duties were carried out using a colour coded cleaning system.

The exterior of the home had been nicely landscaped, with a large garden which had been well tended. There was also a large car park. It was clear that in good weather, tables and chairs were available to sit outside.

–  –  –

How we inspect and report on services We conduct two types of inspection;

baseline and focussed. Both consider the experience of people using services.

 Baseline inspections assess whether the registration of a service is justified and whether the conditions of registration are appropriate. For most services, we carry out these inspections every three years. Exceptions are registered child minders, out of school care, sessional care, crèches and open access provision, which are every four years.

At these inspections we check whether the service has a clear, effective Statement of Purpose and whether the service delivers on the commitments set out in its Statement of Purpose. In assessing whether registration is justified inspectors check that the service can demonstrate a history of compliance with regulations.

 Focussed inspections consider the experience of people using services and we will look at compliance with regulations when poor outcomes for people using services are identified. We carry out these inspections in between baseline inspections. Focussed inspections will always consider the quality of life of people using services and may look at other areas.

Baseline and focussed inspections may be scheduled or carried out in response to concerns.

Inspectors use a variety of methods to gather information during inspections. These may include;

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