Inspection on 15/04/05 for 27 Brockleaze

This inspection was carried out on 15th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

27 Brockleaze 16/09/08

27 Brockleaze 12/09/07

27 Brockleaze 09/11/06

27 Brockleaze 14/10/05

27 Brockleaze 25/11/04

27 Brockleaze 26/05/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Brockleaze (27) Neston Corsham Wiltshire SN13 9TJ Lead Inspector Jacqui Burvill Unannounced 15 April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brockleaze (27) Version 1.10 Page 3 SERVICE INFORMATION Name of service Brocklease (27) Address Neston Corsham Wiltshire SN13 9TJ 01225 811902 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) United Response Mr Simon Phillimore - to be registered Care Home Only 3 Category(ies) of LD Learning disability 3 registration, with number PD Physical disability 3 of places Brockleaze (27) Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 No more than 3 services users with either a learning disability or a physical disability Date of last inspection 25 November 2004 Brief Description of the Service: 27 Brocklease is a detached bungalow in the village of Neston, close to the towns of Chippenham and Corsham. The home is in a rural location. There is a pub fairly close by and a shop a short drive away. This is one of a number of homes run by an organisation called United Response. There is a new manager in post who has yet to complete the fit person registration process. 27 Brocklease provides care and accomodation for three service users aged between 18 - 65 years who have a learning disability. Each service user has their own single bedroom. There are no hand washbasins and no lockable units in bedrooms. There are two bathrooms. There is a lounge, a small dining room, a kitchen and a separate utility room. There is a large garden with parking for several cars. There are two sleep in rooms for staff, one doubles as an office. Until last month, there were two staff sleeping in. This has recently reduced to one, with the inspectors agreement, as one service user has moved. Two staff are on duty each day. Brockleaze (27) Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over part of one day, taking place over three and half hours. Records such as care plans, risk assessments, medication records, staff training records and fire safety records were looked at. There was also a tour of the premises. The inspector spoke to two staff who were on duty and the manager, who came in later during the inspection. The inspector spoke to one service user, who was not able to comment directly on the care received. The home currently has one vacancy. What the service does well: What has improved since the last inspection? Since the last inspection, the staff team have been fully occupied with managing aspects of changes for a service user. During this time, the new manager has been fully involved in supporting the team, and they have found him to be supportive and approachable. Because of the changing needs and managing the care of the other service users, the team felt that their communication and team effectiveness had improved. Brockleaze (27) Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brockleaze (27) Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Brockleaze (27) Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 No new service users have been admitted to the home for a number of years. These outcomes were not looked at during this inspection. The Statement of Purpose has not been amended as required by the previous inspection. EVIDENCE: The Statement of Purpose was not held in good condition, as it was in two parts. It had not been updated. Brockleaze (27) Version 1.10 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, and 9 The care of service users is being compromised by the use of care plans that are inconsistent with different methods of recording in use. EVIDENCE: Care plans need to be consistant, with the range of records required to be held in the one file. One care plan needs to be used as the model for the other, so that care needs for all service users are clearly laid out and easy to follow. Service users have individual plans, which contain sections based on the care needs of the service users. Both plans are not set up in the same style or format. One file contains all of the information that is required, whilst for another service user, there are two other files that also contain information. One of the plans was clearer and more up to date than the other, containing a more detailed range of the care that is to be provided. The daily notes record show that service users are offered a lot of different choices during their day. Service users have some communication needs and staff were observed responding to the requests of a service user and discussing the plans for the day, as there had been some recent changes. Brockleaze (27) Version 1.10 Page 10 Risk assessments were appropriate to the needs of the service user and there is a system in the home where staff sign to say they have read the individual risk assessments, which are reviewed annually. There are guidelines for staff to follow when managing challenging behaviour, enabling care and support to be more individual and directed. Review notes from annual meetings are also held in the care plan file and show that a range of needs and objectives are identified as part of the report and action of these is discussed. Brockleaze (27) Version 1.10 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 Service users have active and fulfilled lives, with their choices and interests taken into account. Service users have positive contact with families and friends who visit the home regularly. EVIDENCE: There have been some changes to the day care activities due to the closure of a service run by the council. Staff from the centre are still in contact with the home and a service user had an arrangement to meet staff for lunch. Contact has been made with the care manager to try and find alternative arrangements. The care plans have a daily activity sheet describing the range of sessions service users take part in. This includes activities in the community, such as swimming and horse riding. Service users are supported by staff when they take part in activities. This is described in the activity plan and in service user’s daily notes. Brockleaze (27) Version 1.10 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Service users receive support from healthcare professionals and staff. There are detailed descriptions for providing personal care and support, which benefit service users. The service users well being may be compromised by elements of medication recording that need reviewed, to include the counting of medication received into the home and what to do and record when an error occurs, as this could affect the well being of service users. EVIDENCE: Both care plan files differ. One includes the medical information and the other has it in a separate file. However, both records are clear about the support service users receive from health care professionals. There are detailed letters following appointments and notes for action taken. The care plan describes the way in which service users like to be supported with their personal care. There is guidance on meeting emotional needs and staff have followed guidance issued by healthcare professionals when gathering evidence. Staff have received medication training, although there is no clear evidence that all staff have done so. There is a weekly audit of medication, with records for the administration and disposal of medication. There is no record of medication received into the home on the MAR sheet or any other record. Where an error had been made, there was not a clear follow up of information Brockleaze (27) Version 1.10 Page 13 to show what action had been taken, such as contacting the GP or the person on call. This omission clearly places the service user at risk. Brockleaze (27) Version 1.10 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These outcomes were not looked at during this inspection. EVIDENCE: Brockleaze (27) Version 1.10 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 30 Parts of the home are in need of repair and replacement. Despite this, the home was found to be clean and tidy on the day of the inspection. EVIDENCE: The home is owned by the Children’s Society. There is going to be a transfer of ownership in the near future. Meanwhile, there are some parts of the home that are in need of repair and replacement. Staff had recently made a list as required at the last inspection, identifying what needs to be done. This will include a new kitchen, for which money has been assigned, some repairs to a doorframe and some redecorating of bedrooms. There are plans to alter the premises that have been put on hold, until the ownership of the home has been sorted out. This includes the kitchen and the bathrooms. The home was clean and tidy on the day of inspection and staff and a service user were observed vacuuming and cleaning. Brockleaze (27) Version 1.10 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Staff training records are inconsistent. It is not clear who has attended what course, as not all of the certificates, or other written evidence is maintained. As a result it is not possible to determine whether staff have the range of skills to meet the different needs of the service users. EVIDENCE: Staff training records are not consistent. Some staff have copies of their certificates in their own files, others do not have up to date records and called the United Response office during the inspection to find out which training course they had taken part in. Some evidence of training was with the NVQ training assessor. Brockleaze (27) Version 1.10 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 42 There is no clear system or report on the standards of quality in the home or the service, based on service users views. Record keeping did not show that staff had received regular fire safety training. This has serious implications for the safety of service users in the home. EVIDENCE: Monthly Regulation 26 visits have taken place and copies of these reports have been sent to the CSCI. Further efforts in establishing a quality assurance system have not been met as set at the last inspection. United Response have a quality assurance system, but it is not clear how this affects the home, or how the views of service users, families and stakeholders are gathered. Fire records show that staff have not had fire safety training in the last quarter of January - March 2005. An immediate requirement was made that staff receive this training by 30th April 2005. Staff were sure they had received training as part of a team meeting, but there was no evidence to support this Brockleaze (27) Version 1.10 Page 18 in the team meeting notes. Fire risk assessments had been reviewed annually and other regular checks were recorded as taking place as required. Master copies are needed in the home so that staff can start using a fresh page for a new year. SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No Score Brockleaze (27) Version 1.10 Page 19 LIFESTYLES Standard No 11 12 13 14 15 16 17 Score x 3 3 x 3 x x 31 32 33 34 35 36 x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x Standard No 37 38 39 40 41 42 43 Score x x 1 x x 1 x Brockleaze (27) Version 1.10 Page 20 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 YA1 Regulation 4 Schedule 1 13(2) Requirement The statement of purpose must contain all of information required by Schedule 1 (Carried forward from last inspection) Medication records must show a count of medication received into the home, with records consistently kept. Staff must receive accredited medication training including homes specific administartion an drelated policies and procedures. (Carried forward from last inspection. Met in part) The manager must make a record identyfying all areas of the home that need work and when this is to be completed. This includes the kitchen and external doorframe leading from bedroom corridor. (Carried forward from last inspection). Staff training records must be clear and show evidence either by a certificate or by a signed and dated record with the name of the course attended. There must be a quality assurance system in use in home. A report on an assessment of quality in the Version 1.10 Timescale for action 15th June 2005 30th May 2005 and from now on. 30th May 2005 2. YA20 3. YA20 13 (2) 4. YA24 23(2) (b) 15th June 2005 5. YA35 18(1) (a) 15th June 2005 and from now on. 30th October 2005 6. YA39 24 Brockleaze (27) Page 21 home must be sent to CSCI by date shown. (Carried forward from last inspection) 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 YA 24 Good Practice Recommendations The internal redecoration of premises continues in order to enhance the current standard of the accommodation. (Carried forward from insepction dated 19th March 2003, 1st July 2004 and 25th November 2005) Staff reviewing care plans should ensure that they record the actual date of review of care plan and date any changes in the interim. The reasons why there are no hand washbasins or lockable units in the service users bedrooms shpuld be described in service users guide and the individual plan. (Carried forward from last inspection) The manager should obtain the fire safety training distance learning pack from Wiltshire Fire Brigade, along with copies of the record forms.( Carried forward from last inspection) 2. 3. YA6 YA26 4. YA42 5. Brockleaze (27) Version 1.10 Page 22 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Chippenham Wiltshire SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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