Inspection on 03/06/06 for Brockenhurst

This inspection was carried out on 3rd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Brockenhurst 14/10/08

Brockenhurst 07/12/05

Brockenhurst 20/07/05

Brockenhurst 17/01/05

Brockenhurst 23/09/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOMES FOR OLDER PEOPLE Brockenhurst 46 Arundel Road Littlehampton West Sussex BN17 7DD Lead Inspector Mrs A Taggart Unannounced Inspection 3rd July 2006 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brockenhurst Address 46 Arundel Road Littlehampton West Sussex BN17 7DD 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) 01903 717984 Ms Norma Ann Matthews Ms Norma Ann Matthews Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (38) Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Brockenhurst is a care home providing personal care and accommodation for thirty-eight people over the age of sixty-five who have dementia. The home is situated close to the town centre of Littlehampton, a seaside resort in West Sussex, with a train station; shops and other amenities close by. Brockenhurst was established in 1974 and has been under the same ownership since that time. The three-storey building consists of two semi-detached properties, which have been linked to form one home. A later ground floor extension has been added and two garages converted to provide a large activities room. There are twenty-eight single and five double bedrooms arranged on all three floors. A passenger lift is also available. There are good size secure gardens to the rear of the property, which are accessible to residents. The home is owned by Mrs. Norma Matthews who is also the registered manager. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out at 9.15am and lasted for seven hours, which covered that early and late shifts worked by the staff team. During the visit the inspector made a tour of the home and saw all communal areas and resident’s private bedrooms. The inspector spent time talking to residents and the staff team, saw lunch being prepared and served and observed interactions and staff practice. A visiting district nurse spoke highly of the home and praised the skills of the staff team and there were also positive views expressed in the 10 comment cards received from families/visitors to the home. Five care plans were tracked with any relevant issues being discussed with the manager or staff members. Four staff files were also seen and each contained the required documentation. The medication administration and storage system was also checked. Other records for the running of the business were seen including complaints books, health and safety, fire and maintenance records and all were in good order. The owner/manager of the home had completed a pre-inspection questionnaire and was present and assisted with information during the visit. Prior to the visit, the inspector read the last two reports and any other relevant correspondence or documentation, completed the necessary planning documents and sent comment cards to residents, families and professionals involved with the home. Current fees are £379 to £520 per week. The inspector thanks everyone who assisted during the visit. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Topical creams should only be used for the person for whom they were prescribed. As good practice it is recommended that alcohol gels or other had-disinfecting methods are made available to visitors. As good practice, as the hot water system is sometimes unpredictable, water temperatures should be randomly tested and recorded on a more regular basis. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 7 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. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13456 Quality in this outcome is Good This judgement has been made using available evidence including a visit to the service. Prospective residents and their families can be assured that the home will carry out pre-admission assessments in order to ensure that the facilities available will meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide have recently been reviewed and updated to reflect the environmental changes within the home. The manager visits prospective new residents in their current accommodation and carries out a pre-admission assessment in order to ensure that the home can meet individual needs. The pre-admission assessment for one new service user was seen and the document contained adequate information to ensure that the person’s health and social care needs were addressed. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 10 During the visit the family of a prospective resident visited the home on their behalf. The manager spent time discussing the person’s needs and gave the people a brochure and Statement of Purpose and took them on a tour of the home. Brockenhurst does not provide intermediate care Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome is Good This judgement has been made using available evidence including a visit to the service. Sufficient current information is available to inform the staff team of the needs of each person they support. Healthcare issues are addressed and medication is well managed EVIDENCE: There is a plan of care in place for each resident, which is generated from the pre-admission assessments. The documents also contain risk assessments, both personal and environmental. The care plans of five residents, including the most recently admitted person were tracked and any relevant issues were discussed with the manager or members of staff. The care plans contained sufficient information to inform the staff team of the needs of each person and the documents had been reviewed and updated on a monthly basis. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 12 Health records show that residents have access to a wide variety of healthcare professionals including local doctors, the community mental health team, chiropodists and hospital specialists. During the visit a district nurse was present twice during the day and was complimentary about both the care provided within the home and the commitment and skill of the staff team. There have been substantial improvements made to the medication system since the last visit. The home has purchased a new medication trolley and separate liquids fridge and the storing and administration of medication have also been improved. The home has an agreement with a local pharmacist who now provides a monitored dose system, which, staff members say, has made the administration of medication safer and simpler to use. Medication was well managed, medication recording sheets were current and in good order and staff receive training through a local college. Staff members were seen to be kind and caring in their dealings with people and were aware of their specific conditions and healthcare needs. Residents moved freely about the home and into the garden area. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome is Good This judgement has been made using available evidence including a visit to the service. The home offers activities and outings to provide interest and stimulation for the people who live there. Families and friends are made welcome and a variety of freshly cooked meals are available. EVIDENCE: The home provides activities including music for health, manicures and music sessions to provide interest and stimulation for people. Twice weekly outings are arranged in good weather using the local community transport and residents enjoy going to the beach or out for tea. Staff members also take people to the shops or out for a coffee. Visitors are made welcome in the home at any time. Residents said that they enjoyed seeing their families and feedback cards comment on how relatives and friends are kept involved in the care of their family member. One family member said, “Staff are well trained, patient and good-humoured. Good food and outings are provided and staff are sensitive to the needs of each individual. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 14 There is a variety of fresh, home cooked food available, including a cooked breakfast if required and special diets such as diabetic and vegetarian meals can be catered for. Lunch consisted of bacon suet pudding with cheese sauce, new potatoes and fresh vegetables, followed by freshly picked strawberries and cream. The food looked attractive and people who needed support were assisted in an unhurried and respectful manner. Residents were very complimentary about the food provided. As the day was very hot, staff members were regularly motivating people to drink water or juice. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome is Good This judgement has been made using available evidence including a visit to the service. Complaints are recorded and acted upon and work practices and staff training are designed to protect residents from the risk of abuse. EVIDENCE: The home has a complaints procedure a copy of which is included in the Statement of Purpose and Service User Guide. One complaint has been logged since the last visit and the manager has investigated and responded to this in line with the home’s published timescales. There is an adult protection and whistle blowing policy in place and the staff team receive training in the protection of vulnerable adults from abuse. There is also a book where staff can record comments or concerns from residents or record ideas for better practice. Staff members on duty were aware of their responsibilities should they suspect an abuse had taken place. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 23 24 26 Quality in this outcome is Good This judgement has been made using available evidence including a visit to the service. He home offers an attractive, homely and safe environment for the people who live there and residents say they are happy with their private rooms. EVIDENCE: The home offers a safe, homely and comfortable environment for the people who live there. There is adequate communal space, which is attractively decorated, small sitting areas are located throughout the house and there is an enclosed easily accessed garden. In the last six months several improvements have been made, including new assisted baths and bathroom equipment, new hoists and medication cabinets and several rooms have been redecorated. A new call bell system has been installed, new fridges fitted in the kitchen and a number of beds replaced. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 17 Bedrooms have been personalised with resident’s own belongings and furniture and people said that they were happy with their private space. Magnetic closures have also been fitted to a number of bedrooms and there is an ongoing programme of redecoration and refurbishment underway. In two bedrooms, jars of topical cream were found, which had been prescribed for another resident. This was brought to the attention of the manager and they were removed. During the tour of the home, some of the water outlets were found to be running too hot. There was a plumber working on the system at the time and by the end of the day the maintenance man was able to demonstrate that all hot taps in resident’s rooms were running at a safe temperature. Mrs. Mathews said that she was considering replacing the boiler and water system in the home as there were recurring problems since recently having major works completed. As good practice, if the system is erratic, water temperatures should be randomly tested and recorded on a more regular basis. The home was clean and hygienic but could be further improved by the fitting of alcohol gels or other hand-disinfectant systems for visitors, to assist with infection control. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome is Good This judgement has been made using available evidence including a visit to the service. A committed, caring, well-trained and well-supported staff team supports the people living in the home and the recruitment process is robust. EVIDENCE: Many of the staff team have worked in the home for a number of years and have an in-depth knowledge of the people they are supporting. There are sufficient numbers of staff on each shift to meet the needs of the current resident group and the staffing rota matched the people on duty. The rota showed that three staff are available during the waking night. Residents said that the staff team were kind and caring and one person said, “they do what they can to make you happy”. One comment card received said, “As a family we have a great regard for all of the staff at Brockenhurst. It is a splendid home, the staff are extremely dedicated to the residents and also give tremendous support to families”. Five staff files were seen and all contained the required documentation, including Criminal Bureau Checks and two references. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 19 There is a programme of training and development in place for each member of staff and as well as mandatory training, people also attend courses such as risk assessment infection control, coping with dementia, abuse training and infection control. One of the senior staff is an NVQ assessor and she confirmed that 80 of the staff team had completed the award. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome is Good This judgement has been made using available evidence including a visit to the service. The manager of the home is committed to providing a good service and updates her skills and knowledge on a regular basis. Records are in good order and there is a quality assurance process in place. EVIDENCE: Mrs. Matthews owns the home and is also the manager. In order to ensure that she is up to date with current legislation the manager attends training to update her skills and knowledge. Most recently Mrs. Mathews has completed, along with two of her senior staff members a year-long course in the National Certificate of Environmental Health Studies and is currently carrying out further courses. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 21 Families speak highly of the manager and the staff team say that she is open and honest in her approach and is also very supportive. One of the residents said, “ Matron is a poppet, very helpful and caring”. There is evidence both from looking at records and speaking to staff members that regular supervision and appraisal takes place and staff meetings are regularly held where there is an update on the current needs of each resident from key workers. A quality assurance process is in place, which elicits views from families and other professionals involved with the home and outcomes are collated and published in a booklet form. Mrs. Mathews confirmed that permission was gained before photographs of residents were included. Each new staff member receives a copy of the home’s policies and procedures and several policies have been reviewed and updated in the past six months. Records for the running of the business were seen, including fire records, maintenance books, gas and electric checks and incident and accident forms, all were current and in good order. Health and safety is a high priority in the home but could be improved by the addition of hand disinfecting gels for visitors and more regular random testing of water temperatures. As previously stated, topical creams should only be used for the person for whom they were prescribed. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 2 Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP38 Regulation 13 Requirement Creams should only be used for the person for whom they were prescribed. Timescale for action 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP38 OP38 Good Practice Recommendations To assist with infection control, it is recommended that hand-disinfecting systems be used within the home for visitors. As good practice, while the hot water system is awaiting updating, water temperatures should be randomly tested and recorded on a more regular basis. Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brockenhurst DS0000014409.V299593.R01.S.doc Version 5.2 Page 25 - 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. 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