Inspection on 15/04/08 for Brighton Lodge

This inspection was carried out on 15th April 2008.

CSCI found this care home to be providing an Adequate 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brighton Lodge 26/06/07

Brighton Lodge 24/05/06

Brighton Lodge 13/01/06

Brighton Lodge 15/07/05

Brighton Lodge 05/01/05

Brighton Lodge 02/09/04

Brighton Lodge 27/04/04

Brighton Lodge 21/08/03

Brighton Lodge 01/10/02

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

CARE HOME ADULTS 18-65 Brighton Lodge 40 New Brighton Road Emsworth Hampshire PO10 7QR Lead Inspector Laurie Stride Unannounced Inspection 15th April 2008 10:15 Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 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 Brighton Lodge DS0000011716.V360996.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 Adults 18-65. 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. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brighton Lodge Address 40 New Brighton Road Emsworth Hampshire PO10 7QR 01243 373539 F/P 01243 373539 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr. David Ernest Clarke Mrs. Ninfa Clarke Post Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th June 2007 Brief Description of the Service: Brighton Lodge is a residential service for twelve adults who have learning disabilities and whose needs are often complex. Brighton Lodge is a large period house set in a street of similar properties. Emsworth village centre is a short walk away. People who use the service are supported to use local amenities. The service is privately owned by Mr and Mrs Clarke who also own another residential service and a day service in Southsea. The fees for the home range from £104.00 to £164.00 per day, based on the level of staffing required by an individual. This information was obtained at the time of the inspection visit. Members of the public may wish to obtain more up-to-date information from the care home. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection, which lasted approximately nine hours, during which we, the commission, looked at how the home was performing in line with the key national minimum standards and also at the progress the service has made in meeting the requirements made at the previous inspection(s). A Statutory Requirement Notice had been served on the provider on 30/11/07, following a failure to inform the Commission of significant and notifiable events or take appropriate measures to ensure people who use the service are protected from abuse and harm. We carried out a random visit to the home on 18/12/07 to monitor the homes’ compliance with the Statutory Requirement Notice. The findings from the random visit were that the home had complied with one of the requirements, while partially meeting another requirement. A further requirement was made as a result of the random visit. Further details are contained in the body of this report. For this key inspection visit we looked at samples of records and spoke with the acting manager, who is applying for registration. We also spoke in depth with two of the members of staff on duty. We met some of the people who use the service, who were either not able to communicate verbally with us due to their needs, or did not wish to at that time, however we observed staff interacting with people who live in the home in a respectful and friendly manner. Further information used in this report was obtained from the homes’ annual quality assurance assessment (AQAA), the previous key inspection report and random inspection report. As part of this inspection, survey questionnaires were issued for people who use the service, relatives, staff and health and social care professionals. No responses had been received at the time of writing this report. What the service does well: The home does well at providing care and support to meet peoples’ individual health and personal care needs. A range of activities are available to people who use the service for relaxation, mental stimulation and learning life skills. Visitors are made welcome and the home keeps in touch with the relatives and Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 6 friends of people who use the service. The home provides wholesome and wellbalanced meals and caters for individual preferences. The home offers a safe, clean and comfortable environment in which to live. What has improved since the last inspection? What they could do better: 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. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home’s assessment and care planning procedures continue to demonstrate that peoples’ needs can be met and an admission policy is in a place with procedures to be followed before any new admission. EVIDENCE: The previous inspection report identified that quality in this outcome area was good. The home had assessment and care planning procedures that demonstrated that individuals’ needs could be met and an admission policy is in a place with procedures to be followed before any new admission. At the time of this inspection, the homes’ annual quality assurance assessment (AQAA) stated that the service provides contracts, a Statement of Purpose and a Service User guide together with policies and guidelines for people who use the service. There have been no new admissions to the service at the last two key inspections and the AQAA confirmed there are currently no vacancies for prospective service users available at the home. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 9 During our visit we saw that people’s needs are re-assessed and care plans are being regularly reviewed and updated. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 & 9 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service benefit through being involved in planning the care and support they receive. Support plans have been improved to reflect individuals changing needs, this would be further enhanced by better recording of peoples’ goals and aspirations. EVIDENCE: During this visit we looked at support plans in relation to three individuals. These records included person centred care plans including use of pictures and photos and also a number of risk assessments and support strategies for each person. Staff told us that the staff at the Day Centre also hold copies and update the support plans. As identified at the previous inspection, there was a lot of information about what people like doing in the care plans but not much evidence of the specific goals and aspirations to be currently worked on. The homes’ annual quality assurance assessment (AQAA) stated that they could do Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 11 better at recording more of their achievements and the achievements of the people who use the service, indicating plans to improve in this area during the next twelve months. Staff members were able to give examples of goals that had been achieved by individuals. Sections of care plans entitled ‘All about me’ gave details of things people like doing, such as shopping, swimming and going to the beach and there was evidence in the daily records of these and other activities taking place. Through discussion with staff it was clear that they knew, understood and worked to the recorded support plans that are in place to meet the assessed needs of individuals. Records are kept of monthly reviews of care plans carried out by the home. We also saw reports of recent reviews of care conducted by social services care managers, together with staff from the home and the Day Centre. The individuals concerned are also invited to attend. At the previous key inspection of 26/06/07, a requirement was made that the service must ensure that the planned physical intervention missing for one person is recorded and follows a risk assessment with evidence of consulting relevant others. Requirements had been made regarding similar issues at the two inspections before that visit. During this visit we saw that support strategies were in place for two individuals whose behaviour can occasionally be challenging to other people. These strategies had been updated in July 2007 following consultation with a psychologist and were being monitored through the homes’ review processes. The previously missing individual risk assessment was in place, together with actions to be taken by staff including a specific physical intervention technique if necessary. The support strategy stated that this intervention was agreed at a multi-disciplinary team meeting. The acting manager said he did not have a copy of this agreement, which occurred before he was in post, but that he would obtain one for the individuals’ file. We did see correspondence indicating that a health professional had been involved in advising staff on behavioural management for this individual. Further to this, the person’s care manager had seen the risk assessments and strategies at a recent review and said that the home is generally providing well for the individual. The care managers’ comments and those of the staff we spoke with confirmed that there has been a reduction in the number of incidents involving this individual. This is sufficient evidence to meet this requirement. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 12 During our visit we observed staff supporting people in making decisions and following these through. We also saw records of house meetings, where individuals decide what is going on the menu and what activities they would like to do. The AQAA stated that the home was to re-run the service user questionnaire and act upon the findings. We saw that this survey had been conducted shortly before our visit and the acting manager said he would be discussing the outcomes with people who live in the home and looking at what further actions to take. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 & 17 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service are supported to make choices and to develop their life skills. The home ensures that a range of social activities, community access and support with maintaining relationships is available to people. EVIDENCE: The previous inspection report identified that quality in this outcome area was good. During the day of our visit the people who use the service were at the day service, where they are able to pursue things that they are interested in. As already mentioned, copies of care plans are held at the day service so that things can be followed through. The homes’ annual quality assurance assessment (AQAA) states that people who use the service give positive feedback demonstrating their enjoyment in Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 14 participating in activities. Also that there is a high participation level in activities of their own choosing. We saw a sample of one of the homes’ service user questionnaires, which indicated that the person was satisfied with the activities they took part in. Activities that people who live in the home enjoy are documented in their care plans and daily records contained details of how people are occupied. The staff are organised so that they are allocated to work with particular individuals when they are at home. The acting manager said that people who use the service don’t often want to go out at night, although this does happen. A member of staff said that people have busy weeks at the day service and that staff encourage people to take part in weekend trips out. The acting manager said that the use of the homes minibus was going to be discussed at a managers’ meeting. The minibus is now mostly used to transport one individual who requires mobility support. The acting manager said that on these occasions other people who use the service also go out in the vehicle. The acting manager said he had begun contacting peoples’ care managers to discuss the use of individual staff members’ cars to transport the majority of people who live in the home. This would mean more flexibility with individuals’ choice of activities, such as one person who likes to go fishing. Records we saw during the visit indicated that all people who live in the home are currently able to access the community frequently. Staff encourage people to have regular contact with family or friends and one member of staff described the support staff provide in this respect. There has not been a recent survey of relatives’ views and the acting manager said that the questionnaire had been updated and would be given to relatives attending reviews this month. We saw evidence of the home consulting with some relatives at reviews. People are encouraged to take part in planning the care and support they receive, including their participation in the daily routines of the home. The AQAA told us that the home offers a wide variety of healthy eating home made meals and provides for any specialist dietary needs for individuals. It said that people who use the service are supported in eating in restaurants, pubs and encouraged to try new foods. We saw that the menu and activities had been discussed at recent house meetings. Pictures are used to assist those who have limited verbal communication. A member of staff orders food from Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 15 the menu book containing peoples’ choices. Personal preferences in relation to food were recorded in individual’s care plans. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 & 20 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The health care and personal support people receive is based on their individual needs. Health care monitoring and recording and medication training promote the safety and welfare of people who use the service. EVIDENCE: Individualised support is provided to people using the service and support for personal care is documented in care plans. Staff members are aware of the emotional and communication needs of the people living at the home and there are recorded strategies in place for assisting with this. The previous report for 26/06/07 described how agreements about funding had delayed the proposed changes to an en suite bathroom to meet the changing needs of one individual. At that time staff at the home had understood that this was soon to be resolved so that a wet room and overhead hoist could be provided. During this visit we learned that the situation has not yet been resolved, we saw records of meetings and correspondence between the Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 17 provider and health and social care agencies. The acting manager said that the provider was going to a meeting the day after the inspection visit to take the matter forward. We also saw evidence of the involvement of an occupational therapist in assessing this person’s needs and providing guidance for staff. We saw recorded evidence of people receiving support from a range of healthcare professionals. Peoples’ health needs are monitored regularly and considered at each review and a file is held for each person with details of appointments and contact with health professionals. Staff members we spoke to were aware of the current needs of individuals and of the agreed strategies for meeting these. The home has policies and procedures for the safe management and administration of peoples’ medication. We saw that medication is stored securely and the acting manager said that any changes to peoples’ medication are confirmed by a letter from the doctor or consultant. The pharmacist had inspected the homes’ arrangements for holding medication on 07/04/08 and found them satisfactory. We saw records stating that individual staff members receive medication training and staff members we spoke with confirmed this. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 People who use the service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. Improvements have been made in the way people who use the service are protected, through clearer reporting procedures and staff training. This is undermined by a lack of good record keeping in respect of complaints and staff recruitment procedures, which puts people who live in the home at risk. EVIDENCE: At the previous key inspection of 26/06/07, the complaints record was asked for but a staff member and the manager were not aware of one. They were aware of the need to record complaints and how they are investigated and followed up. Since then, the homes’ annual quality assurance assessment (AQAA) stated that the home had received one complaint and we discussed this with the acting manager. There was no record in the home of the complaint or of any action taken and a requirement has been made. The acting manager said he would ensure a complaint log is put in place, including the outcome of any complaints and actions taken. The AQAA also stated that regular residents meetings and key worker meetings are held where individuals can discuss any concerns and complaints. We saw records of this during our visit. The two staff we spoke to felt that they would be able to identify if a service user had concerns or was dissatisfied, through monitoring of changes in the persons’ behaviour and mood, which are Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 19 recorded in the daily records. Staff members are trained in techniques including assertion and active listening. We observed staff responding in a calm and reassuring manner to one individual who had become anxious and agitated. The service provider had been issued a statutory requirement notice in November 2007, in respect of a failure to follow correct safeguarding and regulation 37 notification procedures. We conducted a random inspection in the same month to monitor compliance with the notice. During that visit we found sufficient evidence that the requirement regarding regulation 37 notification had been met. For the current inspection we looked at the homes’ recent incident records and none of those we saw were notifiable under regulation 37. (See also the section on Conduct and Management of the Home). The random inspection visit we carried out on 18/12/07 identified that all staff had received in-house training on safeguarding adults, undertaken on 05/12/07. Staff members were aware of where the policies and procedures are kept and their contents. A requirement was also identified at the time, that all staff including the manager and senior staff are as a result of training fully aware of the protocol for collecting facts and responding correctly to allegations when they have been made. During this key inspection visit, the acting manager demonstrated his awareness of the correct procedure, for example ensuring individuals are safe, making factual records including times, dates and people involved and informing the relevant external agencies immediately. Staff we spoke to also stated they would report any suspicions to the manager immediately, or if the manager were involved they would report to the next senior person. One of the staff also talked about recording factual notes and identified various forms of possible abuse, such as physical, emotional and financial. We saw that the homes’ safeguarding policy and procedure was updated in February this year and staff sign to say they have read and understand the procedures. This is sufficient evidence to meet the requirement. Both staff members demonstrated knowledge of the support strategies in place for individual service users and confirmed they receive training in physical interventions. Both staff members indicated that pro-active support strategies were working well, resulting in positive changes in individual behaviours and a reduction in the number of incidents, so that physical intervention has not been necessary for a long period. This was further confirmed when we looked at the home’s incident report records. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 20 In addition to monitoring purposes, the acting manager said that the incident reports are used for staff training, so that all staff members are made aware of developing strategies for working with individuals in a consistent way. A requirement has been made regarding staff recruitment procedures (see the section on Staffing), which the home must meet to demonstrate that people who use the service are fully protected. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People using the service continue to be provided with a clean, safe, wellmaintained and comfortable environment. EVIDENCE: The previous inspection report identified that quality in this outcome area was good. During this visit we undertook a tour of the premises accompanied by the acting manager. People using the service have a spacious open plan lounge/diner, which opens onto a large well maintained garden. People have their own bedrooms and those we saw were clean, well decorated and well maintained, although plans to improve the suitability of accommodation for one person have been delayed for a considerable time while agreements about funding are being worked out. People who live in the home are able to move freely about the communal areas and to use the kitchen and laundry areas. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 22 The home continues to employ separate staff for cleaning and all areas are clean and free of odours. Although there was no indication in the AQAA or records sampled of staff having received any infection control training, a member of staff said that they were made aware of the relevant policies and procedures during their induction. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 & 35 People who use the service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. The homes’ record keeping has improved to demonstrate the training that staff members receive to ensure they can meet people’s needs. Further improvement is needed to ensure the home operates a robust recruitment process to protect people who use the service. EVIDENCE: The previous inspection report identified requirements in relation to staff pre employment checks and training records. The homes’ annual quality assurance assessment (AQAA) states that all staff members have to have an enhanced Criminal Records Bureau check (CRB) before they start employment, as well as two suitable references. For this inspection we looked at a sample of records regarding two recently employed staff members. Both files contained evidence of completed application forms, two references, Protection of Vulnerable Adults (POVA) checks and induction records. There was evidence of a completed CRB check for one staff member Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 24 but not the other. There was no evidence that the staff member without the completed CRB check was working in a supervised capacity, although the rota indicated that other staff members were on shift at the same time. A lack of adherence to recruitment procedures was noted at the previous inspection and a requirement has been made in this report. The registered person must ensure that there is a system in place to follow up any CRB checks that are not received. The acting manager said he would chase up the missing CRB check and would also be using a new recording form that would clearly show the date that new staff members commence working on. An improvement since the last inspection has been the introduction of a file containing evidence of pre-employment checks carried out for day service staff who may work in the home on an occasional basis. Training records have also been improved since the last inspection and this requirement has been met. We saw a sample of these records in relation to four members of staff, which indicated that staff receive training in, for example, medication, first aid, moving and positioning, food hygiene, fire safety and risk assessment. Other relevant training included autism, managing abusive behaviour, epilepsy, mental health awareness, safeguarding and National Vocational Qualifications (NVQ). Staff members said that the training provided is very good and confirmed that NVQ training is offered and the acting manager stated that the majority of staff have obtained or are working toward the qualifications. Through discussion with two members of staff and looking at the homes’ records, it was evident that staff members receive monthly formal supervision and there are staff team meetings every two weeks. Meetings are also used for training and updates on ways of working and the staff members we spoke to have a good knowledge of the current support strategies for people who use the service. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 41 & 42 People who use the service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. Improvements in the management of the service promote the wellbeing and best interests of the people who live in the home, which will be enhanced by there being a registered manager in post. Further improvement is needed to ensure that procedures are adhered to and all relevant records are kept in the home, to demonstrate that the home listens to people and that people who use the service are protected. EVIDENCE: The previous inspection report identified that the management of the home had been disrupted by a change of manager with insufficient quality assurance in place to ensure that all policies and procedures, including health and safety, were fully implemented to support and protect people using the service. Two Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 26 requirements were made in relation to Regulation 26 visits, quality assurance and risk assessments, which during this visit we found had been met. The acting manager has been in post since May 2007 and is in the process of applying for registration. He is also planning to register on a course to obtain NVQ level 4 in care and the Registered Manager’s Award when details of the revised course become available. The homes’ annual quality assurance assessment (AQAA) states the annual development plan for quality assurance was reviewed in March 2008. We saw records demonstrating that the service provider carries out monthly monitoring visits under regulation 26 of the Care Homes Regulations. A service user quality survey questionnaire was carried out by the home in March this year, the results of which the acting manager was in the process of evaluating to see what further action may be taken. We saw evidence of service user house meetings and care reviews, showing other ways that the views of people using the service are being sought. The acting manager is aware of the importance of obtaining the views of all stakeholders in order to monitor the effectiveness of the service, and he informed us that an updated relatives’ questionnaire would be issued this month. The most recent development plan for the home included updating the training programme for staff. We saw that the home has an environmental risk assessment that includes aspects of fire safety. The acting manager had on his list of things to do an update of the fire risk assessment. In a telephone conversation following our visit, the acting manager said he would contact the fire and rescue service to ensure that the current fire risk assessment covers everything it needs to under the relevant legislation. A risk assessment had not been carried out in relation to the garden pond. The acting manager said he would ensure this was done and there have to date been no incidents affecting service users in this respect, so a requirement has not been made on this occasion. Records are kept in the home of tests on portable electrical appliances, services on the hoist, fire alarm system and fire safety equipment and fittings. Fire safety training for staff is also recorded. Since the previous inspection there have been improvements in staff training records, incident reporting procedures, safeguarding procedures, risk assessment and quality assurance monitoring. Further improvement is required Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 27 in relation to complaints record-keeping and staff recruitment procedures, to ensure the views and concerns of stakeholders are taken seriously and that people who use the service are protected. During our visit the acting manager demonstrated his awareness of regulation 37 notification procedures and the latest guidance in relation to this. Since the inspection visit the service provider has notified us of an incident that the acting manager was made aware of but failed to report. The service provider is addressing this with the acting manager. Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X 2 3 X Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 29 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA22 Regulation 17 (2) schedule 4 (11) 19 (11) schedule 2 Requirement A record of all complaints received including action taken must be maintained in the home. Records of pre employment checks must be held for all staff providing care in the home. Where POVA First checks have been obtained pending completion of a full CRB check, these staff must be supervised and this must be demonstrated by the home. Timescale for action 16/05/08 2. YA34 16/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Brighton Lodge DS0000011716.V360996.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!