Inspection on 26/06/07 for Brighton Lodge

This inspection was carried out on 26th June 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brighton Lodge 15/04/08

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 Ms Sue Kinch Unannounced Inspection 26th June 2007 2:00 Brighton Lodge DS0000011716.V339109.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.V339109.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.V339109.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 Mrs Sarah-Jane Mouhsine Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2/11/06 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. Service users 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 £150 to £220 per day. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over seven and half hours over two days and was unannounced. The visit followed a review of the file and submission of an Annual Quality Assurance Assessment (AQAA) document from the provider Mr Clarke, which the current manager contributed to. One of the forms provided to the home to distribute to people using the service and relatives was completed and returned to CSCI. Some people using the service and staff were delayed in returning to the home after day services due to a gas leak nearby. This affected residents and staff routines and in turn this affected their time available to talk with the inspector and led to the inspection being continued on a second day. However, conversations were held with three of the nine people living at Brighton Lodge, three staff members, the manager and Mr Clarke. Observations were made of interactions between staff and people living in the home and some of the shared and private areas of the home were seen. A number of records and documents were also read. Since the last inspection the registered manager has resigned from her post and a new manager has been in post since May 2007. This report also refers to the random inspection carried out on 2/11/06, which found that the requirements of the inspection on 24/5/06 had been met. This inspection included a further monitoring of them to assess if this had been sustained. Findings are detailed in the report. . What the service does well: The environment is safe, clean, well maintained and accessible to service users. Staff are very positive focussed on getting to know the people using the service well. They continue to work in a structured and supportive way with individuals but also socially and emotionally. They are flexible and adapt to day-to-day matters influencing their work. Staff work with a range of people with complex needs, a number of whom rely on non-verbal communication. Staff are supported to develop skills to communicate effectively and enhance participation. Staff members are allocated to work with particular people on each shift and are able to offer continuity. This is also aided by close working with the day service that most people attend regularly. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 6 People using the service are asked about the things that they like doing and this is reflected in their care plans. They have been supported not only to pursue their day-to-day interests but also with holidays and days out that they said they enjoyed. The home consults with people using the service through the review process and their relatives so that their views can influence the service they receive. Care needs are regularly reviewed and person centred plans are provided in accessible formats. 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 Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 8 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.V339109.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s assessment and care planning procedures demonstrate that service users’ needs can be met in the home and an admission policy is in a place with procedures to be followed before any new admission. EVIDENCE: As found at the last key inspection there have been no new admissions to the home but there is evidence of work recently added to the person centred plans showing that people using the service have re assessments. The three plans sampled were detailed and included information such as their likes, dislikes, wishes and aspirations. Plans continue to be individualised by drawings and photographs. Other written evidence was seen and this demonstrated that reviews had taken place. Brighton Lodge DS0000011716.V339109.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Resident’s benefit from being involved in care planning and reviews but the system for risk assessment with consultation and developing strategies used for dealing with behaviour including physical interventions are mostly but not always documented to ensure staff follow the same procedures and needs are met safely and appropriately. EVIDENCE: A sample of three records were viewed and person centred care plans including use of pictures and photos are available for each person and staff said that copies are also held at the day service. There are also a number of risk assessments and support strategies for each person. There was much 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. This could be developed further although examples of goals achieved by present and past residents were provided by a member of staff. In addition staff and residents gave examples of things they liked doing such as shopping and going to the zoo and there was evidence that these things had taken place recently. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 11 In discussion with the staff there was a commitment to working individually using recorded strategies assessed as appropriate with each person. The communication needs of one person was discussed with a member of staff who was developing skills and knowledge in this area. Another staff member was effectively using Makaton signs and gestures during the inspection. In a sample of files it was noted that there were a number of individual risk assessments that had been recently reviewed. These risk assessments included action for staff to take to minimise risks. A risk assessment regarding behaviour for one person was missing on both days of this visit although staff said that a physical intervention of a two-person escort is used. This intervention was not recorded although records were looked at separately with a member of staff and the manager. Although a staff member said that this person had just been reviewed there was also no written evidence of a multiagency agreement for a restrictive intervention. This was discussed with the manager and a requirement has been made again. Significant changes have occurred for three people using the service enhancing their privacy,dignity,and choice. It was reported by the managment in the AQAA that they now have single rooms. This was confirmed at the inspection visit. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Following consultation people using the service are able to be involved in a range of social activities community access and support with relationships. Daily routines ensure residents are able to make decisions and rights are respected. EVIDENCE: At the beginning of the first day of the inspection all residents were at day services where they are able to pursue things that they are interested in. Staff and day service staff said that copies of care plans are held at the day service so that things can be followed through. Residents are encouraged to go to the day services daily but flexibility in this was noted, as on the second day one person was too tired to go and stayed at home. At the same time another resident stayed at home for an appointment and the day service worker arrived at the home to work with the resident. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 13 Activities that people using the service enjoy are documented in their care plans and three people were spoken to about what they like doing. All said that they did do the things that they liked doing such as shopping, going to the zoo, day trips, and visiting relatives. Daily records contained details of how people are occupied. The staff are organised so that they are allocated to work with particular residents when they are at home. The manager said that residents don’t often want to go out at night as well although this does happen and on the first evening of the inspection one member of staff went out with one of the residents. The manager said that issues at the last key inspection raised about residents having access to the minibus at weekends and how this would be financed, had been resolved and residents do use the minibus regularly as well as local transport. Staff encourage people to have regular contact with family members and one member of staff described the support given with visits to family members. No further survey has been made of parent views since the last key inspection but there is evidence of them attending reviews. Not much feedback was received about family contact from people using the service on this occasion but staff were appropriately sharing information from two sets of relatives during the inspection visit and liaising with them. One person living at the home did say that they could spend time with friends when they wanted to. People using the service and staff spoke of regular house meetings where all are people living in the home can be involved in planning the menu. A menu was seen and identified who had made choices. Personal preferences in relation to food were recorded in individual’s care plans. One service user was observed assisting in the preparation of the evening meal. Another asked if they could have an alternative if they did not want the food in the menu and this was confirmed. Both people using the service who were asked about food said that it was ‘all right’ and both confirmed that they could make choices about it. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 14 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): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service receive regular positive support with health and emotional care based on assessed needs recorded in person centred plans and involving other heath professionals as necessary. EVIDENCE: Individualised support is provided to people using the service and support for personal care is documented in care plans. One member of staff described the changing needs of one service user and proposed changes to the en suite bathroom in order that changed needs can be met. Agreements about funding had delayed the changes and the member of staff and manager now understood that this had been resolved so that the wet room could be provided. A meeting was to take place later on the second day of the inspection to discuss aspects of this. In the meantime the member of staff said that they had guidance including some from an occupational therapist for supporting this person. There was verbal and written evidence that people using the service are supported by a range of health professionals as needed. Each person’s health needs are considered in reviews and written evidence of this was seen. A file Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 15 is held for each person where details of appointments and contact with health professionals is stored although not all of this was up to date and some outcomes of appointments were not recorded. However, in one instance where two blood tests had not been recorded, a letter and staff comments provided sufficient evidence that support had been given. There is evidence that people using the service are involved and aware of plans and appointments. One person using the service said that they had seen a doctor and a dentist and had just received an appointment from the hospital. That person said that staff would take them. Another person said that staff helped when they were ill and a dental appointment was to take place next month. Staff are aware of the emotional needs of the people living at the home and there are recorded strategies in place for assisting with this. Staff were flexible in their approaches and showed concern following the delay in the bus returning people from the day services and long waits in traffic queues on the day of the inspection. Communication skills are also worked on with people being encouraged to use Makaton signs and pictorial aids. There was evidence of these in use during the inspection. Detailed medication procedures remain in place at the home and those described by a member of staff were in line with accepted policies. These procedures were readily available for staff and included a system for checking each other’s actions. Drugs are held securely and administration sheets sampled had been signed. There was evidence in 3 of the 5 files observed of medication training. In two files the induction process, which involves shadowing and monitoring, and signing on several occasions had not been completed. Induction and medication was discussed with one of the two people and the person was able to describe the process in line with the induction process recorded. The manager was not aware of the Royal Pharmaceutical Society Guidance and a copy was not available. He was advised to obtain one for assessing the home’s practices. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 16 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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management have created an atmosphere in which people using the service are able raise issues and be listened to. People have benefited from improvements in staff reporting incidents fully and involving other agencies where necessary. EVIDENCE: In the last key inspection report there was a requirement about ensuring that all incidents detrimental to the well-being of the residents are reported to the commission and that procedures are followed after incidents. This was monitored in November 2006 at a random inspection and had been addressed. Since then a number of incidents have been reported to the commission and under the adult protection procedures. At this inspection monitoring took place and from observation of a sample of daily records there was sufficient evidence that reporting was taking place as necessary. This was discussed with the manager who was aware of the in-house procedure for reporting to management by staff and he said that he monitored recording daily. He was aware of the need to report matters detrimental to the well-being of residents to CSCI under regulation 37. He was aware of the adult protection policies and procedures being available in the home but was not aware of the respective roles of the various local organisations in adult protection procedures but said that currently details of all incidents are forwarded to the provider Mr Clarke. The manager was advised of the role of Adult Services and to familiarise himself with this. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 17 Adult protection was discussed with a member of staff who said that the staff had received training by an external trainer in late 2006. However work is needed to ensure that records reflect the training provided and to ensure that new staff receive this training. The member of staff was aware of elements the local reporting procedures and was aware of and had been involved in adult protection meetings. In the AQAA referred to above it was reported that the home had not received any complaints since the last inspection. 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. People using the service are able to talk to staff about issues of concern. One member of staff said, in discussion about working with a particular resident, that the resident is able to let people know when unhappy about something and that staff have communication guidance and enough experience of the person to be able to address needs and wishes. One resident said that they had told the staff about a problem and they had helped him to sort it out. The manager said that there was a complaints procedure for residents, which the staff talked through with people from time to time. During the inspection it was noted that the staff working with people were listening and acting on their wishes. The people coming back from the day service were bringing some items for tea, they had been delayed and this was noted to be stressful for one person, staff were providing emotional support. Staff are trained in techniques including assertion and active listening to help them with this. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are provided with a clean, safe, well-maintained and comfortable environment. EVIDENCE: Shared areas of the home were viewed. These are spacious and people using the service have a large open plan lounge/diner, which opens, onto an equally spacious garden. All residents have their own bedrooms and three were viewed with people happy to show them. All were clean, well decorated and well maintained although plans were in place to improve the suitability of accommodation for one person. People using the service are able to move freely about the home and were also using the kitchen and laundry areas. One person when asked about how quickly things were fixed when broken said that things did not often need fixing. The home continues to employ separate staff for cleaning and all areas are clean and free of odours. Infection control was discussed with the manager Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 19 who was aware of the home having a policy and disposable gloves being in the home for staff to use. However, there was no indication in the records sampled of staff having received any infection control training. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 20 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): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a committed and caring workforce but to demonstrate that people using the service are supported by competent staff through robust recruitment procedures, supervision and training, recording must be improved. EVIDENCE: On the day of the inspection the gas leak in Portsmouth led to delays in traffic and people returning home. This affected household routines and therefore opportunities for talking with staff individually were limited at this visit. However, in the conversations held staff showed an understanding of the need to work with individuals in different ways and of the need to use varied strategies and approaches. Staff approaches were caring and client focussed. One resident said that staff are ‘all right’, another said they were all ’lovely’. Two other people asked chose not to be consulted. Staff spoken with about specific issues were aware of their roles and responsibilities. The home continues to employ four staff in the evenings for nine residents and that includes some one to one support. Training continues to be encouraged in the home and much of it is provided in short sessions run by a trainer employed across the company. Other training Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 21 such is in dealing with behaviour and physical interventions is also provided. Mr Clarke is involved in providing staff training and said he had recently been updated as a physical intervention trainer. One staff member spoken with spoke of training this year in moving and positioning, behaviour and physical interventions, first aid, assertion, and valuing people. In the AQAA the management stated that more training is planned in valuing people and person centred planning. Training is also provided sometimes in staff meetings. However, the staff training records sampled in the home are incomplete and it was not possible to assess for example, numbers trained in all specific areas. This includes adult protection, infection control, valuing people and personcentred planning. Physical intervention training records were amended during the inspection and enough evidence for this specific training was in place in records sampled. But in the two files sampled for evidence of induction, records had not been fully completed and this includes details of medication induction. Accurate written evidence is needed to demonstrate that all staff have had training and supervision to meet the needs of people using the service. For one person recruited since March 2007 records were held of one supervision and no induction training. Recruitment has taken place since the last inspection but prior to commencement of the new manager. The recruitment process and recording was discussed with the manager and records were sampled. Most of the pre employment checks were in place. However, one member of staff had commenced employment after POVA First check but the supervision arrangements prior to the full CRB check being completed were not recorded. For another person the start date was not recorded and therefore it could not be checked that the CRB was completed before commencement of work or if a POVA First check had been needed. On the second day of the inspection a member of the day centre staff worked at the home. A staff member said that the person was providing day care but that at times other people working in the organisation worked at Brighton Lodge to cover shifts. No records were at the home for any of these people. It was explained to the provider Mr Clarke on the first day of the inspection that records were to be held of anyone providing care in the home unless alternative arrangements had been made with CSCI and then some records would need to be held. A requirement has been made in respect of this. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home has been disrupted by a change of manager with insufficient quality assurance in place to ensure that all policies and procedures including health and safety are fully implemented to support and protect people using the service. EVIDENCE: Since the last inspection of the home the registered manager has resigned and a new manager commenced employment at the beginning of May 2007. At this inspection the manager was getting to know the residents, undergoing induction and familiarising himself with the management tasks for the home. He has relevant previous experience but not in registered residential care and was familiarising himself with the implications of the Care Standards and Act 2000 and the Care Homes Regulations 2001. He is also planning to obtain NVQ level 4 in care and the Registered Manager’s Award but is not yet registered on a course. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 23 In the AQAA provided by Mr Clarke before the inspection it was reported that the residents and relatives had been consulted and that action had been taken based on the findings. At this inspection it was noted that the service plan referred to at the last inspection date 2005-2006 had entries to indicate that elements of actions planned had been completed or were ongoing. A new plan was not yet in place. Mr Clarke said that the process of consultation was about to begin again. Other aspects of quality assurance were discussed with the manager who said that the responsibility was with the providers while he was being inducted into the role. However although the providers are regularly in the home there was no evidence in the home of regulation visits having been carried out since March 2nd 2007.A requirement was made about this following the last key inspection. The manager was not aware any other quality assurance system in the home for monitoring practices. The manager is aware of how to establish one. How the home addresses health and safety was considered. The staff training records indicate that staff are trained in elements of this but are not detailed enough to confirm that enough takes place. In the four files sampled three had received training in moving and handling and in fire, none in health and safety, none in infection control. In talking with a member of staff the level of training provided did not appear to be reflected in the records and it is strongly advised that they are updated. A sample of the evidence of equipment checks required in the home showed that the mobile hoist, in house fire checks and gas check had been completed within the appropriate timescales. The risk assessments for the house were requested to be viewed. These were not available and a member of staff said that they were under review. Therefore it was not possible to confirm that these identified control measures such as testing water temperatures and effectiveness of the use of window restrictors or that they were monitored. These are all needed in the home. However, no obvious signs of hazards were noted during the inspection. Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 24 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 x 3 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 x 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 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 2 x x 2 x Brighton Lodge DS0000011716.V339109.R01.S.doc Version 5.2 Page 25 no 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 YA9 Regulation 13 Requirement You must ensure that the planned physical intervention missing for one person is recorded, follows a risk assessment with evidence of consulting relevant others. Timescale for action 17/08/07 2 YA34 19 schedule 2 18 3 YA30 4 YA39 26 This is an amended requirements from the inspections of 13/1/06 and 24/5/06 Records of pre employment 17/08/07 checks must be held for all staff providing care in the home to offer full protection to people using the service. Staff training records need to 26/08/07 fully reflect the training that staff receive in for example in medication, infection control. health and safety and adult protection to demonstrate that they are being provided with training to meet the needs of residents. Regulation 26 visits must be 26/08/07 carried out and a copy held in the home with other evidence of quality assurance to demonstrate that the care DS0000011716.V339109.R01.S.doc Version 5.2 Page 26 Brighton Lodge provided to people using the service is evaluated. This is an amended requirement from 13/1/06 and 24/5/06 Evidence that risk have been assessed and control measures monitored must be in the home to demonstrate that the risks to residents are continually monitored and minimised. 5 YA42 13(4)(a) 26/08/07 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.V339109.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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.V339109.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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