Inspection on 13/11/08 for Brentwood Care Centre

This inspection was carried out on 13th November 2008.

CSCI found this care home to be providing an Poor service.

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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brentwood Care Centre 27/02/02

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Brentwood Care Centre Larchwood Gardens Pilgrims Hatch Brentwood Essex CM15 9NG     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Michelle Love     Date: 2 0 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 41 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 41 Information about the care home Name of care home: Address: Brentwood Care Centre Pilgrims Hatch Larchwood Gardens Brentwood Essex CM15 9NG 01277375316 01277375473 brentwood@ranccare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Debbie Belinda Bantick Type of registration: Number of places registered: Ranc Care Homes Ltd care home 112 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number number of service users who can be accommodated is 112 The registered person may provide the following category of service only: Care home with nursing - Code CRH N to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling into any other category who are over 60 years of age - Code OP (maximum number of places 112) Service users with dementia who are over 50 years of age - Code DE (Maximum number of places 112) Service users with a physical disability who are over 40 years of age - Code PD (Maximum number of places 9) Date of last inspection 112 0 9 Over 65 0 112 0 Care Homes for Older People Page 4 of 41 Brief description of the care home Brentwood Care Centre is a newly built care home situated on the outskirts of Brentwood Town. The home provides accommodation and nursing care for up to a maximum of one hundred and twelve people. Accommodation is provided over three floors. Residents have access to comfortable communal areas and all residents have single bedrooms with ensuite facilities. The costs for placement at the home at the time of this inspection ranged from 562.52 to 1,535.10 per week. Care Homes for Older People Page 5 of 41 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key inspection. The visit took place over two days by one inspector and lasted a total of 18 hours, with all but one key standard inspected. Additionally, the managers progress against previous requirements and recommendations from the last key inspection were also inspected. Prior to this inspection, the registered provider had submitted an Annual Quality Assurance Assessment. This is a self-assessment document, required by law, detailing what the home does well, what could be done better and what needs improving. Information given in this document has been incorporated into this report. As part of the process a number of records relating to residents, care staff and the Care Homes for Older People Page 6 of 41 general running of the home were examined. Additionally a partial tour of the premises was undertaken, residents and members of staff were spoken with and their comments are used throughout the main text of the report. Prior to the site visit, surveys for relatives, staff and healthcare professionals were forwarded to the home for distribution and for people to complete and return to us. Where surveys have been returned to us, comments have been incorporated into the main text of the report. The manager and other members of the staff team assisted the inspector on both days of the inspection. Feedback on the inspection findings, were given as a summary to the manager on the first day and on the second day of inspection, feedback was provided to both the manager and the Director of Nursing and Operations. The opportunity for discussion and /or clarification was given. As a result of concerns relating to poor medication practices and procedures, an Immediate Requirement Notice was forwarded to the registered provider. What the care home does well: What has improved since the last inspection? What they could do better: Further development is required in relation to care planning and risk assessing processes, so as to ensure that individual plans of care are comprehensive, up to date, reflective of peoples current care needs and ensure that the care provided to residents, meets their specific requirements. Additionally, people living at the care home and/or their relatives need to be more actively involved within the care planning process. Practices and procedures for the safe handling, administration and recording of medicines must be improved to ensure that residents are protected. Further training and personal development is required for staff to ensure that they have the skills and competence to meet residents needs. Particular attention must be provided for those conditions associated with the needs of older people. Additionally staffing levels/staff deployment at the home must be maintained at all times, so as to ensure that people living in the home are kept safe and have their safety and wellbeing needs met. Recruitment procedures within the home are not robust and require reviewing so as to ensure that people living in the care home are protected. Staff supervision for staff needs to be improved as currently this is not undertaken regularly. The management team of the home needs to review the routines of the home so as to make sure that peoples individual choices are taken into account, that people are treated with dignity and respect and the home is run for the residents and not to suit the staff team. The manager must ensure that the ethos of the home supports the rights of the people living there. Complaints management needs further reviewing so as to ensure that people living in the home and their representatives feel assured that their concerns/issues will be dealt Care Homes for Older People Page 8 of 41 with effectively and in a timely manner. 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 41 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 41 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst prospective residents can expect to be assessed prior to admission, they cannot be assured that their care needs will be met or that they will be provided with up to date information about the service, which will enable them to make an informed choice about where to live. Evidence: There is a Statement of Purpose and Service Users Guide in place for Brentwood Care Centre. This provides specific information about the service so that prospective residents have the information they need so as to make an informed choice as to whether or not this is the right care home for them. On inspection of both documents, there is evidence to show that some of the information recorded is inaccurate and does not happen in practice. Examples of this are highlighted throughout the main text of the report. The AQAA details that all prospective residents are issued with a copy of the homes Service Users Guide. Care Homes for Older People Page 11 of 41 Evidence: There is a formal pre admission assessment format and procedure in place, so as to ensure that the staff team are able to meet the prospective residents needs. In addition to the formal assessment procedure, supplementary information is sought from the individual residents placing authority and/or hospital. As part of the inspection process, three care files for the newest people to be admitted to Brentwood Care Centre were examined. These showed that all pre admission assessments were completed prior to the persons admittance to the care home. Pre admission assessments were noted to be relatively informative, however not all formal assessments (falls, nutrition, pressure area care, dementia, continence) were completed. For example the care file for one person newly admitted to the care home recorded them as having severe dementia, however the dementia assessment (pre admission assessment) had not been completed. Care must also be taken to ensure that information recorded within both the pre admission assessment and placing authority assessment are transferred to the individuals care plan. There was little evidence to show that the pre admission assessment process had been conducted with the resident and/or their representative or that the person had been offered an opportunity to visit the home prior to admission. The AQAA details under the heading of what we do well, we encourage all prospective clients and families to look around at any time-dont require them to book prior to visiting and each service user has an individualised pre admission assessment to ascertain whether the home can meet their needs. From discussion with the homes administrator, written confirmation that the home can meet the needs of the individual person are not undertaken at this time. Care Homes for Older People Page 12 of 41 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Significant and serious shortfalls in care planning, risk assessing and poor medication practices and procedures means that residents cannot be assured that their needs will always be met or that their health and wellbeing will be maintained or proactively managed. Evidence: As part of this inspection, a random sample of 7 care files were examined. Records show there is a formal care planning system in place to help staff identify the care needs of individual residents and to specify how these needs are to be met by care staff, however not all areas of identified need were recorded within each persons care plan and in some cases there was limited information recorded as to how staff were to proactively manage the persons specific care needs. Additionally, formal assessments relating to dependency, manual handling, pressure area care, nutrition, falls and continence are also completed for individual people. Records show that further development of the care planning and risk assessment Care Homes for Older People Page 13 of 41 Evidence: process is required as shortfalls identified, potentially place people at risk of not having all of their care needs met and provides staff with inaccurate and not up to date information about individual people who live at the Brentwood Care Centre. The AQAA details under the heading of our evidence to show that we do it well, care plans and risk assessments. On the first day of inspection, the care file for one person was examined in relation to their challenging/inappropriate behaviours. It was concerning that the pre admission assessment and placing authority assessment made reference to the above, however the care plan was not compiled until 12 days after their admission to the care home. Although the plan of care made some reference to the persons aggression/inappropriate behaviours, there were no clear guidelines for staff as to how to proactively manage the persons behaviours. Daily information records showed many occasions whereby the resident exhibited both verbal and physical aggression, however these did not always record staffs interventions. On inspection of the persons challenging behaviour record, inconsistencies were noted whereby when cross referenced with the persons daily information records, not all incidents of aggression/inappropriate behaviours were recorded. The care file contained no risk assessment, identifying the above and how the risks were to be minimised so as to provide clear guidelines for staff. From discussions with staff, we were advised of another resident who could on occasions be resistant to care and/or exhibit aggression/inappropriate behaviours and was at risk of falls. In relation to the latter, the falls risk assessment recorded them as being at high risk, however no care plan or risk assessment was devised. Additionally no plan of care/risk assessment was devised in relation to their aggression/inappropriate behaviours. The care file for the newest person to be admitted to the care home was examined. This showed that they were admitted the previous day prior to the first day of inspection, however no plan of care and/or risk assessment was recorded. A pre admission draft care plan recorded the person as requiring assistance with all aspects of personal care, having severe dementia, appearing to have lost weight/requiring assistance to eat their meals, non-compliance with medication and unable to weight bear. Staff spoken with confirmed they had insufficient up to date information about the resident and were aware that the care plan/risk assessments from the persons previous placement were not up to date and had not been regularly reviewed and updated. Staff spoken with advised they have not always been provided with sufficient information prior to the persons admission to the care home. Additionally we were advised that there was an occasion a few months ago, wereby a resident was admitted to the home and staff were not made aware of this until they arrived at the care home. The RGN spoken with stated that staff have up to 72 hours to complete a plan of care for individual residents. A copy of the policy and procedure pertaining to care planning Care Homes for Older People Page 14 of 41 Evidence: was requested from the manager so as to verify the above statement. No policy and procedure was available and the manager confirmed that she was unaware of the above procedure. The care file for one person showed that over a significant period of time (since 2007), they have continued to lose weight and have a poor appetite. The care plan made reference to this, however records showed limited evidence as to the proactive measures undertaken by the management/staff team to address the above. There was evidence to show that a plan of care was devised in relation to the individuals weight loss and this was evaluated. Records recorded that the persons food intake should be recorded daily, for their weight to be recorded weekly and supplement drinks to be provided. Professional visitors records showed in January and March 08, the persons GP visited, however information relating to outcomes for the visits were limited. The care plan evaluation notes also made reference to the person experiencing frequent episodes of vomitting, however there was no information recorded to show this had been followed up and managed. On inspection of nutritional records for the above person, these were noted to be inconsistently completed with gaps not detailing food/fluid taken and records showed from December 07 to October 08 the person was weighed monthly and not weekly as detailed within their plan of care. This lack of a thorough assessment and monitoring of the residents nutritional needs, means the resident may be at potential risk of not having their care needs met. No risk assessment was devised in relation to their nutritional care needs. Of those care plans inspected there was little evidence to suggest these had been devised with the resident and/or their representatives and in some cases the care plan had not been regularly reviewed and updated. This is not in line with the organisations Statement of Purpose which details, All Service User Care Plans are reviewed every 28 days or before should the need arise. These will be done by the Named Nurse/Key Worker in conjunction with the service user and/or their advocate which may be a relative or friend identified by the service user and their participation approved by the service user. The majority of care files examined showed limited evidence that these were person centred and/or individualised. Observations throughout both days of the inspection showed the care needs of some people are not being met. This relates specifically to some people having to wait for long periods of time before personal care is provided and some people waiting for long periods of time before call alarm facilities are answered by care staff. One resident spoken with advised on the second day of inspection that they had been waiting for over 2 hours to have assistance with washing and dressing. This was not an isolated case. Relatives surveys returned to us recorded, My relatives main complaint is the length of time they have to wait for a response to the alarm, often leaving them in severe discomfort, The call alarms are always buzzing and staff are sometimes slow to respond and The regular staff are generally Care Homes for Older People Page 15 of 41 Evidence: able to meet [name of resident] needs, but agency staff (especially at weekends) are often not well enough acquainted with them to meet all their needs. Other surveys recorded usually and sometimes the care home meets the needs of your friend/relative. Only 1 survey recorded that the home always meets the needs of their member of family. One resident spoken with stated they were very unhappy that they had been provided with insufficient continence pads and this had resulted recently, with them wearing one pad throughout the day and having to change their trousers and underwear frequently throughout the day. The AQAA details under the heading of what we could do better, care planning does not always reflect the whole person-more training and regular supervision and audits will continue to support the staff to the standard we expect. Under the heading of how we have improved in the last 12 months, improved our care planning systems to ensure a person centred approach. The latter did not concur with the inspectors findings. Medication practices and procedures were examined within 3 out of 5 units (Sandringham, Windsor and Kensington). The majority of medication is managed through a monitored dosage system (blister pack). Medication is stored within each unit and this was noted to be secure. However during the medication round on the first day of inspection, the medication trolley was left open and unattended for a timed period with medication easily accessible to residents, staff and visitors to the care home. Evidence also showed there was no record of some medicines having been given to the resident when they were due, as the entries on the Medication Administration Record (MAR) had been left blank and not signed or initialed by staff e.g. the MAR record for one person showed they did not receive their Simvastatin medication for a period of 4 consecutive days. From talking with the unit manager and from evidence of daily care records, professional visitors record and clinical records, there was no rationale recorded for the above and the unit manager was unable to provide an explanation as to the above. Where some residents consistently and/or regularly refuse medication, there was little evidence to show what proactive steps were being undertaken by the staff to address the above. For example the care file for one person recorded they regularly refused their medication, except their medication for diabetes. Records showed this was evaluated regularly, however there was little evidence to show what actions were being undertaken by the staff team to address the above. We recognise from evidence recorded within the persons professional visitors record, clinical notes and daily care records that the persons GP was contacted, however there was limited information recorded detailing the outcome from the visits and/or staffs interventions e.g. one daily care record detailed, [name of GP] has documented that [name of resident] is refusing their medication and message for [name of GP] to review [name of resident] as refusing tablets and due to recent bleeding-blood is not co-agulating. Care Homes for Older People Page 16 of 41 Evidence: It was concerning that there was no follow up information recorded detailing the latter and actions taken to address the above. No risk assessment was devised in relation to their continual refusal of medication. The MAR records for several people recorded they were prescribed once weekly medication (Alendronic Acid or Risedronate Sodium Tablets), however from discussions with nursing staff on duty, it was evident that this medication was not being administered in line with the prescribers instructions e.g. to be given 30 minutes or 60 minutes prior to the person having food and not administered with other medication. Staff spoken with demonstrated a lack of awareness and understanding regarding the above. Additionally, on the day of inspection, Alendronic Acid for one person was not administered, resulting in the resident not receiving their prescribed medication on the due date. The nurse spoken with confirmed they had forgotten to administer this persons medication. It was also noted that the MAR record for one person recorded they have medication which is due once onthly. Records showed this was not administered on the due date as the MAR chart recorded, may not have been available. The latter was not an isolated case and other MAR records showed that other people were not administered their medication as not available and awaiting delivery. This refers specifically to Sodium Valporate 300mgs for one person, not being available on 2 consecutive days (4 doses) and Dipyridamole Syrup not available for one person on 3 consecutive days (6 doses). No evidence was available to evidence actions undertaken by staff/management team of the home to address the above. Where a variable dose of medication can be administered (1 or 2), the specific dose was not always recorded. The care plan and MAR record for another person recorded they were prescribed Lorazepam as PRN (as and when required) medication. No PRN protocol was devised detailing the purpose of the above medication and the instances when, this should be administered by staff. The records also recorded the same person as regularly refusing to take their medication and that they could be non-compliant. The care plan was noted to not be explicit as to how their care needs were to be met and no risk assessment was devised for the above, detailing the steps taken by the staff team to minimise the risk. The daily information records for the same resident also recorded on several occassions since their admission to the care home that as a result of their refusal/non-compliance to take 2 medications, these were crushed and mixed with yoghurt. There was evidence to show that this action by staff is regularly conducted. The above was not recorded within their plan of care and a risk assessment had not been devised. There was no evidence to show that the above actions had been discussed with the persons GP and other parties. No evidence was available to show that the above had been discussed with the pharmacist and advice sought as to the continued effectiveness of the above medications being crushed and mixed with Care Homes for Older People Page 17 of 41 Evidence: yoghurt. The above is not in line with the organisations Covert Administration of Medicines to a Service User policy and procedure. This details, before the covert administration of a medicine there must be involvement with the multi-professional clinical team and the supporters of the service user and an agreement that this approach is required in the circumstances. Those involved should include nurses, carers, relatives, advocates and the multi-disciplinary team, which should include the pharmacist for the home or alternatively the pharmacist used by the Commission for Social Care Inspection. The policy also details that a risk assessment and plan of care must be drawn up. Following the discussions with the manager we were advised that they were unaware of the above procedures being undertaken by staff. During both days of the inspection we observed the medication rounds within 2 units not completing until 11.15 a.m. (Windsor) and midday (Sandringham). The lunchtime round on Windsor was noted to commence at 13.25 p.m. and complete at 13.50 p.m. The timespan between the morning and lunchtime doses of medication could mean that some people may receive their medication too soon and be at risk of an overdose. As a result of the above areas of concern, an Immediate Requirement Notice was issued. The training matrix provided to us recorded all staff who administer medication as having up to date medication training. From discussions with the manager, we were aware that at the time of the first day of inspection, no members of staff were observed to have evidence that they are regularly assessed as to their continued competence. On the second day of inspection, 3 members of staff had been assessed. Medication audits for each of the units were examined since April 2008. Records showed that one unit (Kensington) in September 2008 scored 97 and rated the Standard of Medication Management as good. Findings and an action plan following the audit had been compiled by the manager. Regulation 26 visits from 16th January 2008 to 20th October 2008 by the Director of Nursing and Operations was noted to have highlighted medication issues in August and September 2008, however there was little evidence to show what actions had been taken to rectify the issues. On previous visits medication records were not examined. Care Homes for Older People Page 18 of 41 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The activities programme generally meets the social care needs of the people living at the care home. Not all residents have their nutritional needs met, which could affect their health and wellbeing. Evidence: Two activities co-ordinators are employed at Brentwood Care Centre, Monday to Friday each week. We were advised from discussion with one activities co-ordinator that this is flexible so as to encompass activities undertaken in the evenings and at weekends. It was evident from observations on both days of the inspection and from discussion with one activity co-ordinator that they are enthusiastic and enjoy their role. A weekly activity programme is devised and this is provided to individual residents and displayed on a noticeboard by lounge areas. On inspection of 4 weeks activities programme, activities available for people included the name game, musical afternoons, crosswords, religious observance, hairdressing reminiscence quiz, mobile library, musical bingo, shopping, external entertainers and organised trips within the local community. In addition to the above activity programme a list of special dates for the month are listed and displayed. For the month of November 08 this recorded Care Homes for Older People Page 19 of 41 Evidence: Lakeside Christmas Shopping, Lunch Club, Musical Movement, Coffee Morning etc. The AQAA details under the heading of what we do well, We have strong links with the community so that service users can access local activities and the community can be inolved in the homes activities. The activity co-ordinator was advised to consider devising the activity programme in larger print and/or pictorial format so as to enable people in the home to make an informed choice. The activities co-ordinator advised that for those people with poor cognitive development/dementia, there is a portable sensory unit which can be taken to individuals bedrooms, memory boxes are readily available and some people are enouraged to participate in the folding of napkins, making beds etc. We were advised there is a 150 pounds per month budget for projects, materials and booking of external entertainers, however this is not always sufficient and the activities coordinators are reliant on fundraising and donations. The activity co-ordinator advised that she loves her job and it can be challenging but is so rewarding, I couldnt want for a better job. We were advised that the aims and objectives of her role as she sees it, is to ensure that people at the care home have their social care needs met in relation to their personal preferences, likes and dislikes. Relatives comments pertaining to the activities provided at the care home were generally positive and included, There is a very good activities programme and They have an excellent social activities co-ordinator who works hard to link in with families and provide entertainment for the residents. Some areas of concern were also highlighted and these included, Feel there is not much activity for those few people with severe dementia. The TV is on all the time and other than entertainment on other floors all there is to do is walk up and down the corridors and Its upsetting for us to see someone just walking up and down and sitting in front of the TV, depressing when you walk onto the unit. We were advised that a Map of Life and activity report is completed for each resident. On inspection of care files for those people case tracked, the above records were readily available. There is an open visiting policy at the care home, whereby visitors can see their member of family and/or friend at any reasonable time. There was evidence to show throughout both days of the inspection, that people living at the care home are actively encouraged and supported to maintain friendships and relationships. The AQAA details, We have completely open visiting arrangements. Within the home there are smaller lounge areas where residents can meet with their friends and relatives in private. Care Homes for Older People Page 20 of 41 Evidence: There is rolling 4 week menu within the home. A menu was displayed within the main reception area and within each dining area. The menu was not available in larger print and/or pictorial format so as to enable people to make an informed choice. Several residents spoken with were unable to tell us the choices available for both the lunchtime and teatime meals. It was noted that not all residents were advised as to the meal available/provided, prior to the meal being served. The lunchtime meal was observed within two units (Windsor and Kensington) and the teatime meal was observed on one unit (Kensington) throughout both days of the inspection. Meals provided to residents were attractively presented and portions of food seen to be plentiful. The lunchtime meal was observed on Windsor during the first day of inspection. The RGN on duty was advised that several residents were seen to be seated within the dining room for between 45-50 minutes prior to the meal being served and this may be too long a period. Where residents required assistance to eat their meal, the majority of staff were observed to provide appropriate support that was both respectful and sensitive to individual residents care needs. However one member of staff was observed to stand when assisting the resident to eat their meal. The resident was overheard to state several times, I dont want it, Ive told you I dont want it and Oh, I couldnt, however the member of staff was observed to ignore the resident and continued to attempt to place a fork of food in their mouth. Although we recognise the member of staff was attempting to encourage the resident to eat their meal, there was no recognition of the residents choice/ability to make a decision. The resident was offered an alternative to the meal (sandwich) and this too was declined. One resident was observed to have their meal placed in front of them for a period of 15 minutes before a member of staff provided assistance. Residents were not provided with a drink until after they had finished their meal. One member of staff when questioned stated this was as a result of concern that some people would only drink and then become reluctant to eat their meal. The manager was advised to consider reviewing this as some people could prefer to have a drink with their meal and/or might find it difficult to eat without a drink. Several residents were noted to have a pureed/soft diet. We were advised that this is provided by an external company. Portions of food were noted to be portioned seprately and looked attractive. The lunchtime meal was observed on Kensington on the second day of inspection. As stated previously the meals provided were observed to be attractively presented and plentiful. All staff working within the unit were observed to interact well with residents and to assist them with support that was both respectful and sensitive. A choice of drinks was readily available for people. The teatime meal consisted of both hot and cold choices e.g. range of assorted sandwiches, soup, cheese and potato layer bake and cakes or a yoghurt. Care Homes for Older People Page 21 of 41 Care Homes for Older People Page 22 of 41 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Appropriate systems are in place to ensure that residents are safeguarded and that any concerns raised are dealt with proactively, however people living in the care home, cannot be assured that staff working within the care home have the skills and competence to deal with people who display aggressive and/or inappropriate behaviours. Evidence: There is a complaints policy and procedure in place and this is clearly displayed. On inspection of the complaints procedure, this needs to be amended to reflect that the Commission for Social Care Inspection no longer investigates complaints. Relatives surveys returned to us, recorded that the majority of people know how to make a complaint and where issues have been raised, these have been dealt with. Since the last key inspection, the complaints log shows there have been 10 complaints. There was evidence to show that complaints received relate to call alarms not being answered within a timely manner, high turnover of staff, poor infection control/hygiene issues within the home environment, issues relating to residents laundry, concern that the double doors between 2 units are now left open and pose a potential risk to individual residents, personal items belonging to some residents have gone missing and concern that some people have not been notified if their member of family has sustained an injury, fall etc. There was evidence to show the specific nature Care Homes for Older People Page 23 of 41 Evidence: of each complaint, investigation undertaken and action taken, however no outcomes were recorded. Additionally it was evident that not all complaints had been responded to by the person in charge of the home, in line with the homes complaints policy and procedure. Several letters and cards of compliment were noted and these were seen to be positive. Since the last inspection there have been 4 safeguarding issues highlighted. We have been notified of all issues and there was evidence to show that appropriate measures were undertaken by the management team of the home and the relevant external agencies were contacted e.g. Local Authority, Police etc. Where the outcome of further investigations remains outstanding, the manager has been advised to formally write to us advising of the outcome. Appropriate safeguarding policies and procedures were available within the home and staff spoken with, were able to demonstrate a basic understanding and awareness of safeguarding procedures. On inspection of the staff training matrix, this showed the majority of staff working within the care home have not received training on safeguarding. Additionally there are some people within Brentwood Care Centre who exhibit inappropriate/challenging behaviours from time to time, yet the majority of staff have not received training on how to deal with the above. Some staff have received training relating to the Mental Capacity Act and Deprivation of Liberty. Care Homes for Older People Page 24 of 41 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a safe, comfortable, homely and well maintained environment which meets their needs. Evidence: A partial tour of the premises was undertaken throughout both days of the inspection. The home is a three storey building and there are 5 units, Kensington and Buckingham on the ground floor, Windsor and Sandringham on the first floor and Balmoral on the second floor. The home is maintained, decorated and furnished to a high standard and provides residents with a homely and comfortable environment. Signage within the care home needs to be improved so as to aid orientation for people residing at the home, especially for those people who have dementia and/or poor cognitive development. The AQAA details under the heading of what we could do better, Our dementia units need to be more environmentally stimulating. The manager advised that a grant has been applied for so as to develop the dementia units. There is a large welcoming reception area on the ground floor and a passenger lift provides access to all floors. Each unit has sufficient communal space (lounge areas and dining areas for residents use). A random sample of residents bedrooms were inspected and all were seen to be personalised and individualised with many personal items on display. Of those Care Homes for Older People Page 25 of 41 Evidence: residents spoken with, all confirmed that they liked their personal space and found the home environment to be satisfactory. Throughout both days of inspection, the home was observed to be odour free, clean and tidy and no health and safety issues were highlighted at this inspection. Two maintenance people are employed at Brentwood Care Centre Monday to Friday for a total of 56 hours per week. The training matrix evidences that the full time maintenance persons training only includes health and safety and fire awareness. From the training matrix there was no other evidence to show they have undertaken training relating to COSHH (Control of Substances Hazardous to Health), Infection Control and Manual Handling. Care Homes for Older People Page 26 of 41 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The level of staffing and staff deployment restricts the ability of the service to deliver person centred care and to ensure that peoples needs, can be met and that they are safe. Inadequate recruitment procedures and insufficient evidence of training for some people mean that residents are not safeguarded and staff working at the care home may not have the necessary skills to meet the assessed needs of residents. Evidence: The staffing levels at the home vary from unit to unit. On Windsor unit the staffing levels are 1 RGN and 4 care staff between 07.45/08.00 a.m. to 20.00 p.m. and 1 RGN and 2 care staff between 19.45/20.00 p.m. and 08.00 a.m. each day. On Sandringham unit the staffing levels are 1 RGN and 5 care staff between 07.45/08.00 a.m. to 14.00 p.m., 1 RGN and 4 care staff between 14.00 p.m. to 20.00 p.m. and 1 RGN and 2 care staff between 19.45/20.00 p.m. and 08.00 a.m. each day. On Buckingham and Kensington units the staffing levels are 2 senior carers and 4 care staff between 07.45/08.00 a.m. to 20.00 p.m. and 2 senior carers and 2 care staff between 19.45/20.00 p.m. and 08.00 a.m. each day. At the time of the site visit, Balmoral unit had only just opened and only one resident was being cared for. Staffing levels for this unit consisted of 1 RGN and 1 member of care staff throughout the day and night. It is unclear as to how the above staffing levels have been calculated. Although we recognise that dependency profiles are completed for all residents, this information is Care Homes for Older People Page 27 of 41 Evidence: not collated to inform the above. The managers hours are supernumerary to the above. Additionally a variety of ancillary staff are employed and these include, chef, kitchen assistants, housekeepers, laundry assistants. The home also employs an administrator and receptionist, Monday to Friday 09.00 a.m. to 17.00 p.m. On inspection of 4 weeks staff rosters these evidence that staffing levels as detailed above have not always been maintained. We have not received any Regulation 37 notifications advising us of the staffing shortfall and measures undertaken to deploy staff to the home. Staff spoken with during the inspection confirmed that staffing levels as detailed above have not always been maintained, particularly at weekends. Staff advised that this impacts significantly on their ability to provide personal care to residents promptly, resulting in some people having to wait a long time before their care needs are attended to e.g. one resident was observed to be quite distressed on the second day of inspection as they had not received support from staff to be washed/dressed (10.45 a.m.) The resident was overheard to state, they dont want to come to me, I dont know why. They advised the inspector that they had been waiting a long time to be attended to. Additionally as previously stated, call alarms for some residents were not answered promptly and two residents were noted to not have their call alarm facility answered for a period of 10 and 13 minutes respectively. From discussions with other residents and from comments noted within relatives/residents surveys forwarded to us, the above were not isolated incidents. Comments included, They are so short staffed that they can not always come when you need them, but this is no fault of the staff-they always do their very best, All of the staff are very kind and caring, but are put under a lot of stress with staff shortages-permanent staff and not agency-most of them just want to sit in the dining room, The problem is there is not enough staff to adequately cope and provide the level of care expected at all times, It appears that they are short staffed and those that are there are often rushed off their feet and sometimes it is hard to find a staff member who is free. I also notice the call alarms are also buzzing some time which may also be due to shortness of staff. One complaint log also recorded that a relative was assiting their member of family with personal care, however they required additional assistance from a member of staff. The complaint log details that both the relative/resident waited for 10 minutes before assistance arrived and during this time the resident became anxious and distressed. Other incidents relating to the above were also highlighted within resident/relative meetings. Staff surveys returned to us confirmed the above. Additionally we were advised that as a result of staff shortages/insufficient numbers of staff available to meet individual residents needs, some poor care practices are being carried out. Staff spoken with advised they are being given instructions by senior staff to lift residents, rather than use manual handling equipment because it is quicker. Staff also advised there is a lack of manual handling equipment within the home and people are having to wait to receive care and support from staff. Care Homes for Older People Page 28 of 41 Evidence: It was evident from our observations on both days of the inspection and within 4 units (Winsdor, Sandringham, Buckingham and Kensington), that staff try hard to meet peoples individual care needs, however this is hampered by the number of residents who have been assessed as having high dependency and who require 2 staff for assistance and/or who require significant input and support from individual members of staff. From inspection of the staff rosters and from discussion with the manager, deputy manager, nursing/care staff and the newly appointed Director of Nursing and Operations, there has been a consistent high usage of agency staff at Brentwood Care Centre over a period of time. Staff advised that wherever possible the same agency staff are utilised so as to provide continuity of care to people living at the care home. It is positive to note that senior members of staff/manager have autonomy to book agency staff as and when required. Where agency staff are utilised, the staff rosters did not include the full names of all staff deployed in the care home on any given shift and from inspection of the staff rosters, it was difficult to decipher on some days, the actual hours worked by some agency members of staff. The staff files for 5 newly employed people were examined. Shortfalls in the recruitment procedures were identified and these relate to no evidence of a POVA 1st/Criminal Record Bureau check for 2 people, only 1 written reference received for one person prior to commencement of their employment, a written reference not provided from the persons most recent employer and no records of induction for any of the 5 people employed in the care home. The administrator advised that profiles detailing agency staffs qualifications/training and confirmation that checks have been completed by the employment agency are provided and readily available. No formal record of induction is completed for agency members of staff, however we were advised that staff are shown around the home. The AQAA details under the heading of what we do well, We undertake a robust recruitment process and carry out various checks on possible employees, for example CRB, references, employment history. This did not concur with the inspectors findings. The training matrix provided to us evidenced training deficits for the majority of staff working in the care home pertaining to both core subject areas such as food hygiene, health and safety, fire awareness, first aid, safeguarding, manual handling and those conditions associated with the needs of older people. From discussions with the manager, nursing/care staff and the Director of Nursing and Operations, all confirmed and agreed that training for staff has not been seen as a priority and needs further development. The manager has reviewed the training matrix to reflect both up to date training and individual training deficits for staff. Additionally there was evidence to show that several courses have been booked for staff to attend in November and Care Homes for Older People Page 29 of 41 Evidence: December 08. Regulation 26 visits as far back as 23/1/08 made reference to the above shortfalls and recorded, Staff training has been neglected due to staffing problems. Hopefully this will improve by March. The Regulation 26 visit for 20/10/08 recorded, training matrix produced. The reports for August and September 08 did not make reference to training. The AQAA details under the heading of what we do well, All staff receive a three day induction and regular training. This did not concur with the inspectors findings. The AQAA details that as of 22/8/08, 20 of staff had attained NVQ Level 2 or above and 8 members of staff were working towards an NVQ qualification. Care Homes for Older People Page 30 of 41 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care home is not run in the best interests of residents and shortfalls and deficits identified could potentially affect positive outcomes for residents. Evidence: At the time of the inspection, the manager had been in post 13 days. The appointed manager was previously the deputy manager at the home and has been employed at Brentwood Care Centre since March 2007. From discussions with the manager, it was evident they have experience working with both older people and with adults who have a formal diagnosis of a mental disorder since 1996. The manager has attained qualifications in mental health training, has undertaken a diploma in palliative care for the elderly and completed and achieved the Registered Managers Award in September 08. Other training relating to core subject areas and the specialist needs of older people is not up to date and this was confirmed by the manager. The manager advised that the ethos of the home is, to provide the best possible care Care Homes for Older People Page 31 of 41 Evidence: to the people living at the care home, to recognise their strengths and to recognise peoples individuality. The Statement of Purpose details the organisations aims and objectives and this states, The main aim of Brentwood Care Centre is to provide personal and nursing care of the highest standard to each of our residents whilst creating a relaxed homely environment. To foster an atmosphere of care and support which both enables and encourages our residents to live as full, interesting and independent a lifestyle as possible with rules and regulations being kept to a minimum. It is evident from this inspection that there are many breaches of regulation which do not evidence positive outcomes for people living within the care home. Shortfalls identified include further development relating to care planning/risk assessing, providing care to individual people in line with their specific care needs, medication practices and procedures, that staff deployment/actual numbers of staff within the home are suitable for the numbers and dependency levels of residents, that recruitment procedures for staff are robust and that there is an appropriate training programme in place for staff. Comments from relatives relating to the management of the home were varied and included, On the whole we feel the balance is good, Generally the home is excellent, but I noticed that more lately staff are leaving, there are more temporary staff and this is having an impact on peoples care, Must maintain its high standards and not let these slip over time and We feel that management staff should show a greater interest in the actual running of the home. A well managed home will be a more stable place for people to work and feel that their efforts are not taken for granted. The Director of Nursing and Operations was present on the second day of inspection and stated that they have been in post for 4 months. They advised that they were aware of the issues as detailed throughout the main text of this report and have undertaken action to try and address these. They confirmed that there has been little leadership on each of the units, no overall head of nursing on Windsor or Sandringham units, huge issues regarding medication, no clear procedures/structures within the home and poor performance by the previous manager to work with the organisation to resolve and address the above areas. Although we recognise the above, there was little evidence on either day of the inspection to show that a robust action plan and/or efforts were being made by the organisation to effectively address the issues and to ensure positive outcomes for people living in the care home. From discussion with both the manager and nursing staff/care staff, records show that the majority of staff have not received formal supervision. One member of staff stated that in 14 months they had received 3 supervisions. Another member of staff confirmed they had only received 1 formal supervision in 14 months and the manager advised that since her employment (March 07) they had received no formal Care Homes for Older People Page 32 of 41 Evidence: supervision. The Regulation 26 visit report dated 3/1/08 recorded, staff supervisions being done in a limited way. The Regulation 26 visit report dated 24/7/08 recorded, supervisions taking place. All sections of the Annual Quality Assurance Assessment (AQAA) were completed and the document returned to us when requested. Information recorded was generally informative and detailed, however it does not give an accurate account of the current situation within the service. Aspects of the document as detailed within the main text of the report provide little or no evidence to support some of the claims made within it. Information relating to the services quality assurance were requested. The manager advised that quarterly audits are undertaken and these include residents views. Audits as far back as July record that the homes care planning processes require reviewing and updating. This was also highlighted in reports undertaken as recently as October 08. In addition to these, Regulation 26 visits are undertaken, however these were not completed for 6 months between February 08 and July 08. Records of staff meetings/unit meetings and relatives/resident meetings were readily available. The AQAA provides a list of policies and procedures currently available within the home. Care Homes for Older People Page 33 of 41 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 29 19 (1) (b) All of the checks as required 30/05/2008 by regulation must be carried before a person is employed the home so as to safeguard the welfare of residents. Staff working at the home must receive training in respect of the roles they are to perform so as to help ensure that the welfare of residents is protected. 30/05/2008 2 30 18(1) (c) (i) Care Homes for Older People Page 34 of 41 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 9 13 Residents must be protected 01/12/2008 from harm by having their medication administered safely. So as to ensure individual peoples health and wellbeing. Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 Risk assessments must be 01/12/2008 devised for all areas of assessed risk so that risks to residents can be minimised. Records must be explicit, detailing the specific risk, how this impacts on the person and steps taken to reduce the risk. This will ensure that risk areas are identified and staff are aware of the associated risks to residents health and wellbeing. 2 7 15 Care planning at the home must identify, and be effective in meeting all residents assessed needs and ensure these are regularly updated and 01/12/2008 Care Homes for Older People Page 35 of 41 reviewed to reflect the most up to date information. This will ensure that staff have the most up to information and can provide appropriate care to meet their needs. 3 8 12 Ensure suitable 01/12/2008 arrangements are in place so as to ensure that residents health and welfare are promoted and any issues are promptly addressed and proactively managed. This refers specifically to ensuring that where people require support, records are updated, staff have the skills to recognise when to contact healthcare professionals and to provide appropriate interventions. This will ensure that the healthcare needs of residents are met. 4 9 13 Ensure that all staff who administer medication remain competent to undertake this task. This refers specifically to regular competency assessments. So as to ensure that staff remain competent and confident to undertake this task and to ensure residents safety and wellbeing. 01/01/2009 Care Homes for Older People Page 36 of 41 5 9 13 Ensure that the medication trolley is not left unattended and medication easily accessible to residents and others. This will ensure unnecessary risks to residents health and wellbeing is averted. 01/12/2008 6 9 13 Residents must be protected 01/12/2008 from harm by having their medication administered safely and in accordance with the prescribers instructions. So as to ensure residents safety and wellbeing. 7 9 17 Ensure that when medication is not administered to residents, records clearly record this, the rationale why they are not and any action taken to address the above This is to ensure a clear audit trail and to ensure peoples health and welfare. 01/12/2008 8 18 13 Ensure that all staff receive appropriate training relating to safeguarding and dealing with challenging behaviour. This will ensure that staff, feel confident, have the skills to deal effectively with issues raised and residents are protected from harm. 01/02/2009 9 27 18 Ensure there are sufficient staff, on duty at all times. 01/12/2008 Care Homes for Older People Page 37 of 41 So as to ensure the needs of residents are met according to their specific needs and dependency. 10 29 19 Ensure that robust recruitment procedures are adopted at all times and all records as required by regulation are sought. This will ensure that residents and others feel assurred that they are safeguarded by the homes procedures. 11 30 18 Staff receive appropriate training to the work they perform. This refers specifically to core subject areas and those conditions associated with the needs of older people. This will ensure that staff, have the competence, confidence and ability to meet residents care needs and people living at the care home will feel reassured that their care needs will be met by suitably trained staff. 12 30 18 All staff newly employed to the care home receive, a structured induction. This will ensure that staff, feel supported and able to carry out their role. 13 31 10 The home is managed appropriately with skill and competence. 01/12/2008 01/12/2008 02/03/2009 01/12/2008 Care Homes for Older People Page 38 of 41 To ensure that the care home is run in the best interests of the people who live at Brentwood Care Centre. 14 36 18 Ensure that staff, receive regular supervision. So that staff feel supported and residents know that staff are appropriately managed. 01/12/2008 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 Review and update the Statement of Purpose and Service Users Guide so as to ensure that information recorded within both documents is accurate and reflective of the services and care practices provided. Record within the pre admission assessment process, evidence that prospective people/representatives are offered an opportunity to visit the care home prior to admission and that they are consulted/involved within the assessment process. Wherever possible, residents and their representatives are consulted regarding the care planning processes. Ensure that nutritional records for people living in the care home are fully completed to evidence food provided. Where a variable dose of medication is administered, the specific dose given is recorded. Consider devising the activity programme in larger print and/or pictorial format, so as to enable people to make an informed choice. Ensure that people living in the care home receive a choice of drinks at mealtimes (Windsor Unit). Consider devising the menus for residents, in larger print and/or pictorial format, so as to enable people to make an informed choice. 2 3 3 4 5 6 7 8 9 12 7 8 15 15 Care Homes for Older People Page 39 of 41 9 16 Complaints should be responded to, in line with the homes complaints policy and procedure and the specific outcome of a complaint clearly recorded. Ensure that laundry systems within the home are appropriate for the people living in the care home. This refers specifically to people having their laundry back in a timely manner and that items of laundry are not lost and returned to their rightful owner. The staff roster should clearly depict the full names of all staff working at the care home on any given shift (including agency staff). 10 26 11 27 Care Homes for Older People Page 40 of 41 Helpline: 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 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 © (2008) Commission for Social Care Inspection (CSCI). 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. 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