Inspection on 25/10/07 for Brendon House

This inspection was carried out on 25th October 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brendon House 10/02/09

Brendon House 26/08/08

Brendon House 14/11/06

Brendon House 27/02/06

Brendon House 20/10/05

Brendon House 08/02/05

Brendon House 18/10/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Brendon House Brendon Avenue Loundsley Green Chesterfield Derbyshire S40 4NJ Lead Inspector Denise Bate Unannounced Inspection 25th October 2007 09:30 X10015.doc Version 1.40 Page 1 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 Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 2 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. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brendon House Address Brendon Avenue Loundsley Green Chesterfield Derbyshire S40 4NJ 01246 347610 01246 347612 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) www.derbyshire.gov.uk Derbyshire County Council Amanda Plumtree Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Brendon House care home is registered to provide accommodation and personal care for service users whose primary care needs fall within the following category: Old age, not falling within any other category (OP) The maximum number of persons to be accommodated at Brendon House is 31 14th November 2006 2. Date of last inspection Brief Description of the Service: Brendon House is situated in the Loundsley Green area of Chesterfield, close to local shops and public transport. The home provides accommodation on two floors and personal care for up to 31 older people. There is an extensive garden, part of which has been fenced to provide a secure area for residents to use. Brendon House is owned by Derbyshire County Council and the authority has plans to provide a replacement building although there are no firm timescale in place at present. Residents and their families have been made aware of these plans. The authority has undertaken a programme of refurbishment that reflects the proposed lifetime of the building. The home provides both short-term respite and long term care provision. Fees charged are as follows: Short-term care - £98.50 per week. Long term care - £301.84 to £381.84 per week. Long-term care fees are dependant on each person’s individually assessed needs. Additional charges are made for hairdressing, private chiropody, newspapers and toiletries. A copy of the home’s service guide is usually available for people in the main reception area. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over eight hours on two days. During the inspection nine residents, four relatives, and four staff members were spoken with. A deputy manager was present during the first day of inspection. He provided assistance and information. In addition several telephone conversations took place and a separate meeting was held with the manager, who was on leave on the first day of inspection. Prior to the inspection a number of sources of information were looked at including the home’s service record and previous inspection reports. An Annual Quality Assurance Assessment (AQAA) was completed by the manager prior to the inspection and information provided has been used in the preparation and presentation of this report. A number of records were examined on the day of inspection, including care planning documentation, minutes of staff meetings, regulation 26 visit records, staff files, complaints book, accident book, staff meeting records, risk assessments and medication records. Three residents were case tracked and care planning documentation and files for other residents were seen. Case tracking involves a random sample of residents, whose care and service provision is more closely examined. We spoke with residents about the care and services they receive. A tour of the building took place and private and communal accommodation was seen. What the service does well: Brendon House provides a comfortable, homely, and relaxed environment for residents. Residents and relatives spoken with made positive comments about the home and staff; ‘I have never regretted my decision to come here’, ‘the staff are very helpful’, ‘the home is very nice’. Communal areas of the home are comfortable and provide a range of areas for residents to use. The home is generally well maintained and clean throughout. The food was said to be ‘good’ and the quality was praised by residents. Staff spoken to received training and support to carry out their tasks. There is a thorough system for recruiting and training new staff and appropriate checks are carried out, although these sometimes take a long time. There is a corporate complaints procedure, although most day to day difficulties are dealt with on an informal basis but are still recorded in a complaints book. There is a clear safeguarding adults procedure and staff have Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 6 received appropriate training, although some established staff need refresher training. Regulation 26 visits carried out on behalf of the proprietor. Records of the visits were detailed, informative, and showed that matters relating to the day to day running of the home are recognised and steps taken to deal with them appropriately. Although there are a number of areas that need to improve the manager has a proactive attitude toward improvements and has made progress since the last inspection. What has improved since the last inspection? What they could do better: On the day of inspection there was not up to date information available about the home. The up to date statement of purpose and service user guide was not freely available to residents and their advocates. Clear information regarding the fee structure was not available. The home did not always have full assessment information on new residents prior to them moving to the home to ensure that the home could adequately meet their needs. Some new residents had not had formal reviews. Work should continue to ensure that care planning documentation is more detailed and of a consistent standard. Work should continue to ensure that all matters relating to medication are in line with current guidance, including ensuring that medication administered is ‘within date’. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 7 A number of good practice recommendations have been made regarding the environment including decoration and maintenance of windows. Improved staffing levels are needed to ensure that residents receive a consistently high quality of care at all times. The programme of activities needs to be carried out consistently and staff should have more one to one time with residents. Dependencies should be monitored to ensure that staffing levels are sufficient to meet residents needs at all times. Matters discussed at the inspection regarding equality and diversity should be addressed, i.e. ensuring that residents are treated with dignity and respect at all times and ensuring that there is always a female member of staff on duty. The results of the recent quality assurance exercise had not yet been made available to residents and their advocates, so the home had not been able to identify how they were to address any shortfalls. 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 summary of this inspection report can be made available in other formats on request. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 8 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 Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People are not sufficiently informed to assist them in choosing a home. The pre admission assessments do not always take place in time or in sufficient detail to effectively account for peoples’ care needs. EVIDENCE: On the day of inspection the statement of purpose was not available. A new service user guide had been prepared but gave incomplete information and was not freely available. Information about the fees charged by the home were not available, other than for short term care. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 10 At a meeting with the manager it was acknowledged that the new versions of the service user guide and statement of purpose had been prepared but the old copies had not been replaced, nor had the new versions been brought to the attention of residents. Some residents have lived locally and know the home. They may have had short term care or day care there prior to admission. The home said they encourage prospective residents or their advocates to visit prior to making a decision to move to the home. The home said they have a system that usually relies on assessments being done by care managers prior to admission. This system is not working satisfactorily and some examples were discussed where residents have moved into the home before a written assessment has been supplied by the care manager. The manager said that the home was also experiencing some computer problems and that these were in the process of being addressed. One resident case tracked had moved in recently and did not have full and up to date information on assessment documents. A relative spoken to had not seen care plan and review had not been held, although the relative was very satisfied with standard of care. The personal service plan was not fully filled in or signed. The manager said that although 72 hour and 6 week reviews should be held, they were not always taking place. As mentioned previously, the fee information available to the home only related to short term care and was not provided in sufficient detail to enable residents to have sufficient information on which to base their decisions. Residents usually have their initial financial assessment done by community care managers or social workers before moving in to the home. Copies of contracts were seen on residents’ care planning documentation and these referred to the statement of purpose and service user guide. Financial assessments are dealt with centrally by a Central Assessments Team and contracts state that letters are sent to residents or their representatives when there are any changes in fees. Items not covered by the basic fee are identified in the statement of purpose and service user guide. Prior to the inspection the manager had identified the need for improving pre admission procedures. The home does not provide intermediate care and standard 6 was not assessed. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s health care needs are reasonably well met and their rights to respect, dignity and privacy are usually promoted. The efficient and timely completion of the revised care-planning format being introduced by the home and regular formal reviews should provide better guidance to staff on how to care for residents. EVIDENCE: The home have developed a system of care planning documentation. Framework I, a new computer based system, has been introduced. Three case tracked residents had clearly arranged care planning files. Items in files included monthly updates written by link workers, personal service plans, risk Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 12 assessments (moving and handling, nutrition), weight monitoring, daily routines and detailed day to day logs. Aspects of residents’ health needs and medication were presented on care planning documentation. However, care plans were not always consistently filled in and did not include all important aspects of resident care. Social, emotional and psychological needs could be more detailed. One recently admitted resident, had not signed her care plan. Only one resident case tracked had a preferred daily routine sheet filled in. As mentioned previously, one recently admitted resident had not had a formal review and the manager said they had experienced some difficulty in organising formal reviews for some residents A number of individual residents were discussed. It was clear that some aspects of resident care, including challenging behaviour, are dealt with by staff but were not clearly identified in care planning documentation. There are usually only 2 staff on duty for 31 residents (including three short term care residents). Staff said that they were very busy and were sometimes rushed. Staffing levels are discussed later in this report. Residents comments included: the staff are very kind, its nice not having to do my own shopping and cooking, we are well looked after, coming here was the best thing I ever did, I do what I can to help the staff by laying tables, the food is good, I like it here. Three residents of those spoken with had difficulty advocating for themselves but appeared relaxed and happy and were willing to chat to the inspector. Four relatives spoken with gave positive feedback but felt the home was sometimes short staffed: this is a wonderful place, the staff are good, they get good care and attention, I trust the staff, staff tell us when something is wrong I can talk to the managers if there’s a problem, the staff are sometimes very busy, they could do with more staff. Derbyshire County Council has a clear policy relating to equality. Staff were observed supporting and reassuring residents. Issues regarding privacy and dignity are generally dealt with sensitively. However, a number of issues relating to equality, diversity and dignity were discussed with managers. One member of staff was observed telling resident to hurry up. It was acknowledged by the deputy manager on the first day of inspection that this was not acceptable. The manager said the home was committed to ensuring that residents were treated with dignity and respect at all times and that issues relating to dignity and respect would be discussed with in supervision and addressed in training. The home has several male staff and there have been concerns expressed by some residents that sometimes there are no female members of staff on duty. The manager said that they try to avoid this. This matter could be addressed by increasing the staff ratios as discussed later in this report. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 13 The home do not formally record resident dependencies, although both managers and staff feel that resident dependencies have increased considerably in recent years. There is a key worker system in place, and key workers write monthly reviews on residents; copies were seen in the files of residents who were case tracked. The home uses the Monitored Dose system (MDS) for medication, and some medication is kept in original packaging for short term care residents. There is a separate medication room where medication is kept securely. Photos of residents are kept with their medication administration records, reducing the possibility of residents being given the wrong medication. However, one recently admitted resident had not yet had her photo taken. The medication records of some case tracked residents were seen and found to have been recorded correctly. The home have a system for recording the date of opening on eye drops and creams. The date of opening on a container of eye drops showed that it had been used for more than the recommended period of one month. This medication was withdrawn from the trolley on the day of inspection. The home have a system for storing and administering controlled drugs. These were checked and found to be correct. The home have access to medication information about particular drugs and their uses and side effects. The home are working to ensure all aspects of the home’s practice are in line with current Derbyshire County Council guidelines and staff have recently had training. A recent inspection by the dispensing chemist had found matters relating to medication to be generally satisfactory. The home had reported to the CSCI that one incident had taken place regarding a mistake in medication administration. The standard relating to end of life wishes was not inspected, but case tracked care planning documentation had residents wishes recorded. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle preferences are usually promoted in accordance with their choices and expressed wishes but residents do not always have access to a choice of suitable activities. Residents receive a balanced nutritious diet which contributes to their health and wellbeing. EVIDENCE: On the day of inspection residents went on an outing to Crystal Peaks. Minutes of residents meetings reflected some discussion about activities, particularly in relation to outings which are now happening on a monthly basis and have included a visit to Bakewell. Regular events include playing bingo, in house entertainment, movement to music, craft, and seasonal celebrations. Information about events and trips are Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 15 on display in the foyer. Some residents enjoy helping and one resident helps run the bingo. However, staff said that sometimes it was difficult to ensure that activities happened because of pressure of routine care work and covering for colleagues. The manager confirmed that activities sometimes don’t happen because there were insufficient staff on duty to meet residents care needs and provide activities. At present the home says the upstairs lounges are underutilised although there are plans for a relaxation area. Some residents gave examples of how they were supported in their daily routines. Some resident preferences were reflected in the ‘daily routine’ part of care planning documentation, but these had not been filled in for everyone. The manager had recognised that improvements could be made in this area and said: more staff such as more activity workers would be able to work with people who have more diverse needs such as dementia/alzheimers so that staff have more time to work on a 1 - 2 - 1 basis and greatly enhance the level of care that service users with these conditions receive. Relatives said they felt residents would benefit from staff being able to spend more time with them, although they felt staff did a good job with the resources available to them. Relatives said they were made welcome. The deputy manager was observed interacting with relatives, who later told the inspector that they he was very helpful. Most residents are local and the culture of the home reflects the local area. The deputy manager said the home had a good relationship with the local community and that residents can access the shops and are known by the shop keepers. Relatives said that the home is very flexible when visitors come for special occasions. Most residents have regular contact with relatives and friends and some go out on a regular basis. There is a dining room where most residents take their meals. All residents and relatives spoken with were happy with the food which they said was good, apart from two people who said that the standard varied. At the last inspection there had been some problems with a supplier but these had now been sorted out. Copies of the menus were supplied and indicate a traditional menu is followed. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and accessible complaints and safeguarding adults procedures are in place to ensure residents can be confident that any issues raised would be acted on effectively and promptly. EVIDENCE: There is a corporate complaints procedure in place, although most relatives and residents prefer to raise issues on a more informal basis. It is the home’s policy to keep a record of minor complaints and the complaints book was seen. This clearly outlined action taken to deal with issues that have been raised. No complaints have been received by CSCI. All residents and relatives spoken with felt they had enough information to raise any concerns Derbyshire County Council has clear procedures for dealing with the safety of residents and safeguarding them from harm. Staff spoken to showed an awareness of safeguarding adults issues and would pass any concerns on to their line manager. Training in safeguarding adults has been provided for staff, although some staff felt they would benefit from updating their training. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with a comfortable and homely place to live. EVIDENCE: Extensive improvements have been carried out since the last inspection. The manager said: Since September 2006 we have undertaken a great deal of redecoration and new flooring of main areas and bedrooms, staff are working hard with service users to personalise their bedrooms taking into account requests and need. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 18 We have had an assisted bath fitted and also a hair dressing style sink and have purchased 2 hydraulic chairs, 2 over head dryers and new towels and pictures to turn our room into a hair dressing salon. A number of improvements recommended last year are still outstanding or need attention. These are: replacement/redecoration of windows, revarnishing the stairs, some lights need cleaning again and some skylights need cleaning. On day of inspection some exterior areas were a bit untidy with leaves, but some of these were cleared up on day of inspection Several residents bedrooms were seen. All had been personalised and were comfortable. Residents spoken with were happy with their rooms, and several had brought their own furniture. All areas on the home seen on the day of inspection were clean and residents and relatives indicated that they were satisfied with the standards of hygiene in the home. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by a staff team who have good training opportunities. However, the management approach to calculating the care staff numbers required does not effectively take account of residents’ needs, which may place them at risk. EVIDENCE: Staffing rotas indicate that most of the time there are only two members of care staff on duty to care for 31 residents, including 3 short term care residents. Resident dependencies are not formally monitored at present, although the manager and staff said resident dependencies had increased in recent years. The home said that there were 2 residents who needed two members of staff to help with their care, leaving no member of staff available to help other residents. Two residents case tracked had challenging behaviour and/or complex needs. Staff, relatives and residents commented that sometimes there did not appear to be enough staff. On the day of inspection the home was not full, but staff were very busy. Some members of staff indicated that the level of work was Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 20 quite stressful, and the general feeling was that they would work more effectively it they had more time to carry out tasks. As mentioned previously, staffing levels have also had an impact on the provision of activities, one to one time spent with residents and formal supervision of staff. The application of recognised management tools for determining care staff levels would indicate that a significant increase in staff is needed. Other problems have been caused by staff sickness and delays in recruitment of new staff, although the manager said that staff rotas (as currently drawn up) had been covered. Staff said managers were supportive, they had supervision and their training opportunities were good. Staff training records were seen, and information provided by the manager indicated that mandatory training is up to date. The manager has identified training that she would like staff to have, e.g. dementia care, diabetes, incontinence, palliative care, end of life and bereavement. In addition, the home said the following training is being undertaken to increase staff qualifications: 1 staff working towards NVQ 1 Cleaning and buildings, 1 Manager about to undertake A1 Assessor training, 1 Manager working towards her NVQ 4 Care and Registered Managers award, 1 Manager studying part-time for BA Hons in Social Work, 1 relief manager undertaking NVQ 4 Care, 2 relief managers about to start NVQ 3 in Care and 3 care staff working towards NVQ 2 Care. Two staff files were looked at and both had the full range of documentation necessary to ensure that evidence of a robust recruitment and selection procedure is in place. Good practice recommendations have been made relating to recruitment and a requirement has been made in relation to staffing levels. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is fairly well managed and is generally run in residents best interests. EVIDENCE: The manager has the registered managers award and is suitably qualified. There are a number of deputies who take responsibility for particular aspects of the running of the home including medication, hotel services, and care Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 22 plans. Over the past year the home have worked to improve standards, and this reflected in the regular staff meeting minutes that take place at every level. The management team have identified areas of work that still need to be addressed on a day to day basis, and they still need to develop ways of working effectively as a team, e.g. ensuring they have a consistent approach to making information available to prospective residents and their advocates (Standard 1). Relatives and residents spoken to said that they could talk to managers about any problems. The regulation 26 visits were informative and showed that the service manager was raising issues regarding quality, and looking in detail at documentation. However, there had been no visit since September 2007 and some items identified in the last report had not been addressed on the day of inspection. The home have developed a more organised administrative system since the last inspection, but there was some confusion among some of the management team about where some documents were kept. Prior to inspection the manager had identified the need to develop more audit systems to make sure their recording is kept up to date. The 2006 quality assurance information took a long time to come through and is now out of date. A further round of questionnaires has taken place, but the home had no idea when the results would be available to share with residents and their advocates. Some residents meetings are held. The information provided by the home indicates that all routine maintenance is carried out satisfactorily. The inspector was informed that at present residents’ personal finance records are kept through Derbyshire County Council’s electronic scheme which appears to work satisfactorily. Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 23 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 1 X 1 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X 3 3 3 STAFFING Standard No Score 27 1 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes 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 OP1 Regulation 4 (1), 5 (1) Requirement An up to date statement of purpose and service user guide must be available to provide information for residents and their advocates. Clear and transparent information must be provided about fees for people within the service guide, to better inform and assist them in choosing a home. (This must accord with that stated under Regulation 5 (amended Nov 06). Residents needs must be assessed prior to them moving to the home and confirmation given to prospective residents that the home can fully meet their needs. Care planning documentation must be reviewed to ensure that there is evidence of up to date personal service plans which have been discussed with residents; and that care plans are consistently reviewed on a regular basis. Care must be taken to ensure that medication is administered DS0000035785.V353597.R01.S.doc Timescale for action 31/12/07 2 OP1 5(1)(b) 31/12/07 3 OP3 14(1) & (2) 28/02/08 4. OP3 15 28/02/08 5. OP9 13 (2) 31/12/07 Brendon House Version 5.2 Page 25 6. OP27 18(1) (a) as prescribed to ensure the safety of residents. At all times staff must be provided in sufficient numbers and skill mix as are appropriate for the health and welfare of people accommodated. 30/01/08 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 OP3 Good Practice Recommendations Care planning documentation should be written in sufficient detail to give staff full information on residents background, and social, emotional and care needs, to residents preferences and choices are met. Photographs of residents should be taken promptly and kept with medication records to ensure that all medication administration is carried out safely. Staff should treat residents with dignity and respect at all times. There should be sufficient staff on duty to ensure that the full activities programme can take place to ensure that residents have a stimulating environment. Arrangements for recruiting new staff should ensure that vacancies are fill quickly to ensure there are sufficient staff to meet residents needs. Refresher training should take place in safeguarding adults procedures for established staff to ensure residents safety. The lights in the corridors should be cleaned. Internal painting of some woodwork on window sills should take place. The stairs should be revarnished to enhance the standard of the environment for residents. The results of the internal quality assurance exercise should made available to residents and their advocates and an action plan drawn up. 2 3 4 5 6 7 8 9 10 OP9 OP10 OP12 OP12 OP18 OP20 OP20 OP20 OP33 Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 26 Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Brendon House DS0000035785.V353597.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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