Inspection on 07/12/05 for Brockenhurst

This inspection was carried out on 7th December 2005.

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 03/06/06

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 Annie Taggart Unannounced Inspection 7th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 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.V268779.R01.S.doc Version 5.0 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.V268779.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 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.V268779.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out by an inspector and the pharmacy inspector and lasted for 5 hours, which covered both the early and late shifts at the home. During the visit the inspector spoke to all of the residents currently living in the home and also to five staff members and two visitors. A tour of the building was undertaken which included the communal areas and all private bedrooms and the inspector saw lunch being prepared and served. Six care plans and six staff files were seen along with other documentation including health and safety records and maintenance reports. The pharmacy inspector tracked all medication procedures and spent time discussing systems with the manager. Prior to the inspection, the last two reports were read along with any other documentation and correspondence relating to the service. The Registered Manager Mrs. Mathews and the senior carer/administrator, Mrs. Robbins assisted with further information during the visit. What the service does well: What has improved since the last inspection? There is a programme of redecoration and re-furbishment underway and several bedrooms have recently been completed. The home continues to improve the systems and procedures and three senior staff members are undertaking an intensive health and safety course. Magnetic fire closures have been fitted to some doors and the programme will carry on until all bedrooms have closures fitted. Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 6 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. Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 7 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.V268779.R01.S.doc Version 5.0 Page 8 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): 23456 Prospective residents are only admitted to the home following a pre-admission assessment to ensure that the home can meet their needs. Visits to the home are encouraged and families are involved. EVIDENCE: The manager of the home visits prospective residents in their present accommodation and carried out a comprehensive pre-admission assessment. The assessments of two new service users were seen and both contained detailed information about the health and social care needs of each person. Visits to the home prior to moving in are encouraged but often families make the visits and discuss the appropriateness of the facilities available. Two visitors were spoken with, their family member had been admitted very recently and they were complimentary about the assessment process and the welcome they were given during visits to the home. Brockenhurst does not provide intermediate care. Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 9 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 11 The health and social care needs of each resident is documented in a plan of care which is reviewed on a regular basis. Wherever possible people stay in their home until the end of their lives. The medicine administration procedure, which does not comply with the Royal Pharmaceutical Society Guidelines, could potentially put residents at risk. EVIDENCE: Each person living in the home has a plan of care in place, which is generated from the assessment process and updated and reviewed on a regular basis. The plans show evidence of input from a variety of healthcare professionals including, the district nurse team, psychiatrists, local doctors and hospital specialists. Plans are updated on a regular basis by key workers and monitored by the manager or deputy manager. Plans include risk assessments and risk management plans and detail nutritional and mobility needs. The home has medication policy and procedures. No residents are able to take responsibility for their medicines. Storage of medicines is in locked cupboards. On receipt medicines were checked in, but receipt was not recorded. Records Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 10 of administration were on the printed charts provided by the pharmacy. Some staff had certificates for a medication-training course completed last year. There was not a list of staff authorised to administer medicines. Two senior staff re-dispensed medicines, into small pots with residents’ names on the lid. A tray of these pots was prepared for staff to administer at each medication round. Care plans seen included records of communication with prescribers about medication changes. Both residents and visitors said that the staff team were very kind and caring and that people were treated in a respectful manner. The family of one resident said that they would like to comment on how the health and confidence of their relative had improved in the short time they had lived at the home. The home has a policy in place, which says that wherever possible, residents can stay in the home until the end of their lives supported by people who know them. The manager and staff team have received a large number of very complimentary letters from families thanking them for their care and support not only to residents but relatives and friends at this time. Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 11 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 The home meets the lifestyle needs of the people who live there. Families and friends are made welcome and there is a variety of healthy, freshly cooked food available. EVIDENCE: There are opportunities for activities including visits from outside entertainers and a list of forthcoming events is posted in the home. Staff members take people out to the shops or for a coffee and occasional larger trips are arranged. Two visitors confirmed that they were always made very welcome at the home and said that they were offered refreshments and a private area to meet with their relative. Because of the frailty of many of the people living in the home it is sometimes difficult for them to communicate choices and take control of their lives, but staff members were seen encouraging people to be as independent as possible and to join in with small household tasks. Menus show that there is a variety of fresh, home cooked meals available and residents confirmed that they really enjoyed the meals provided. Lunch on the day of the visit was roast chicken, roast potatoes and three fresh vegetables Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 12 and alternatives were available if required. Special diets can be catered for including diabetic and pureed meals. Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 13 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): Residents and their families can be confident that their complaints and concerns will be listed to and acted upon. Legal rights are protected and policies and procedures are designed to protect people from 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. There have been no complaints recorded since the last visit. The manager said that as most of the people living in the home would find it difficult to make a formal complaint the staff team try to respond to “grumbles” and concerns as soon as possible. Residents are registered on the electoral role and they and their families have access to an advocacy service, details of which are posted in the home. The home has a “Whistle Blowing” policy and most of the staff team have now attended training in the protection of vulnerable adults from abuse. Mrs. Mathews said that training would continue until all staff members had attended. Staff members were aware of their responsibilities should they suspect an abuse had taken place. Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 14 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 2021 22 23 24 25 26. The home offers a warm and homely environment for the people who live there. Private bedrooms have been personalised and necessary equipment is in place. The home is clean and hygienic EVIDENCE: The home is warm and comfortable with adequate communal facilities and an attractive enclosed rear garden. Resident say they are happy with their private bedrooms, which have been personalised with people’s own furniture, pictures and ornaments. Most bedrooms have washable floors but some are carpeted. There is a programme of redecoration underway and several bedrooms have been completed with new furniture in place and new flooring fitted. The house is light and airy and residents were seen to move about freely. There are sufficient toilets and bathrooms available. Some are now looking a bit “tired” but Mrs. Mathews said there was a plan in place to upgrade the facilities in the near future. Handrails, grab rails and other equipment is in Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 15 place to aid mobility and Mrs. Mathews said that the district nurse team provide specialist equipment when needed. In the past six month there has been a programme in place to fit magnetic fire closures to all doors. In most of the house doors were closed or were safely opened using the correct equipment but in the annexe several doors were wedged open therefore posing a hazard should a fire occur. Mrs. Mathews asked the staff to immediately remove these wedges. The home is clean and hygienic. Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 16 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 There is a caring and committed staff team in place who are aware of the needs of the people they support and staff receive training. There are risks associated with recruitment procedures. EVIDENCE: Most of the staff team have worked in the home for many years and have built up good relationships with the people they support. The rota shows that there are sufficient numbers of staff available to meet the needs of the current residents. On the day of the visit there were five care staff, a senior carer/administrator, a cook, laundry person and a handyman on duty and the manager were also working in the home. The staff team are aware of the changing needs of the people they support and comprehensive shift-change meetings are held to pass on relevant information and discuss problems. There is a robust recruitment policy in place and new staff are only employed after having undertaken an interview process and receiving two references. However errors were found in the records of the last two members of staff to be employed in that although Criminal Bureau Checks had been applied for the clearance - or a POVA First check had not yet been returned. Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 17 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): 31 32 33 34 35 36 37 38 Brockenhurst is managed by a caring and competent manager who runs the home in the best interests of both residents and the staff team. Financial procedures are robust and records are generally well kept. EVIDENCE: Mrs. Mathews is a qualified nurse who has owned and managed the home for many years. Mrs. Mathews continues to update her knowledge and skills and is currently undertaking a year- long course in the National Certificate of Environmental Health Studies. The deputy manager and senior carer are also attending the course and the home has gained from this by an improvement in health and safety awareness and enhanced and improved procedures. The staff team speak very highly of Mrs. Mathews and said that she is both very professional and supportive. Staff members confirmed that they received supervision and documentation showed that a programme of yearly appraisals is currently underway. Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 18 Mrs. Mathews confirmed that there is a financial plan in place for the home and this includes a programme of redecoration and refurbishment. Financial affairs for residents are managed by relatives or legal representatives and any transactions taken on behalf of people are invoiced by Mrs. Mathews on a three monthly basis. The home has a quality assurance programme where views of residents, families and other professionals involved with the home are gained through feedback forms. The replies are collated and published on an annually. To ensure that confidentiality and dignity are maintained, agreement should be gained from residents or their families before photographs of residents are used in the document. Records for the running of the business were seen including insurance, maintenance records, incident and accident forms and fire equipment and most were current and in good order. As previously stated medication procedures and records need to be improved. Recruitment procedures need to be revised and to ensure the safety of both residents and staff; wedges should not be used on bedroom doors. Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 19 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 X 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 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 3 18 3 1 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 1 Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 20 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 OP9 Regulation 13 (2) Requirement The procedure for medicine administration must be reviewed and staff that administers medicines must be trained in the new procedure. Receipt of medicines must be recorded. To ensure that people are protected in the event of fire wedges should be removed from bedroom doors. All new staff members must have a current CRB in place before taking up employment. Timescale for action 01/04/06 2. OP19 13 (4) 06/12/05 3. OP29 19 06/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations A list should be maintained of staff who are authorised to administer medicines, including their specimen signatures and initials. Brockenhurst DS0000014409.V268779.R01.S.doc Version 5.0 Page 21 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.V268779.R01.S.doc Version 5.0 Page 22 - 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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