Inspection on 12/04/06 for Brockhurst

This inspection was carried out on 12th April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brockhurst 30/09/08

Brockhurst 13/06/07

Brockhurst 20/09/05

Brockhurst 18/04/05

Brockhurst 07/10/04

Brockhurst 14/04/04

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

CARE HOMES FOR OLDER PEOPLE Brockhurst Brox Road Ottershaw Surrey KT16 0HQ Lead Inspector Helen Dickens Unannounced Inspection 12th April 2006 10:00 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 Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 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. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Brockhurst Address Brox Road Ottershaw Surrey KT16 0HQ 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) 01932 872635 01932 872862 Surrey County Council - Adults & Community Care Mrs Tina Marie Davis Care Home 46 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (32), of places Sensory impairment (1) Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Accommodation and Services may be provided to named persons aged 60 - 65 years with the prior written agreement of the NCSC. Respite Care may be provided to a maximum of 5 persons at any one time, these persons should be grouped into the same unit. Intermediate Care may only be provided in Aster Unit for up to a maximum of 4 Service Users Camellia and Carnation Units will be used solely by Service Users who require Dementia Care. A maximum of 6 Services Users with Dementia may be cared for in other parts of this Home. 20th September 2005 Date of last inspection Brief Description of the Service: Brockhurst provides care and accommodation for older people over the age of 65. It was purpose built in the 1970s and is owned and managed by Surrey County Council. It is located in Ottershaw, near Addlestone, in a quiet residential area, close to local amenities. Accommodation is arranged in seven units on two floors, all rooms being single. Each unit has its own bathroom and toilet facilities, a kitchenette, and a communal lounge/dining area. The reception area, main kitchen and laundry are on the ground floor and there are offices on both floors. There is a lift and stairs to the first floor. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to March 2007. The inspection was carried out by Helen Dickens, Link Inspector for the service. Tina Davis, Registered Manager, and her Deputy Melissa Bruty, represented the establishment. A tour of the premises took place. Five residents, three staff and two visitors were interviewed. The inspector also spoke with several groups of residents and other members of staff throughout the day. Four residents files were examined, including their care plans and needs assessments. Four staff files were also considered. A number of other documents were also examined as part of the inspection process. This was a positive inspection and the inspector would like to thank the residents, relatives, staff and management for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 6 All the Requirements from the last inspection have either been met or partially met. Complaints are now investigated within the correct timescales; the home has obtained its own copy of the February 2005 Surrey multi-agency procedures for the protection of vulnerable adults; all the maintenance matters raised at the last inspection have been addressed; and the home have been carrying out falls audits on a two monthly basis. The number of falls and reportable incidents has reduced over the last 6 months, compared with the first 6 months of the financial year April 2005/06. Care plans and resident documentation have also improved. The manager has also carried out the Residential Forum Matrix calculation to check that staff/resident ratios are within acceptable limits. The overall decoration of the home has improved and this is discussed later in the report. What they could do better: Though care plans have improved greatly over the last year, there is still some work to be done to ensure all residents have accurate and regularly reviewed care plans. The quality assurance processes set up by Surrey county Council involve pairs of care homes assessing each other on a cyclical basis. The sister home to Brockhurst has been unable to participate in these arrangements for some time and therefore this requirement is still outstanding. The registered manager said they hoped to re-start the process in May/June 2006. There were some medication issues raised on the day of the inspection and advice was passed on from the CSCI pharmacy inspector which is detailed in the report. There are still a high number of agency staff being used within the home, and a high number of falls; both of these matters are discussed later in the report. Concerns regarding the high usage of agency staff and the belief that the home is constantly ‘short’ of staff came up when speaking to residents, relatives and staff during the inspection. On the day of the inspection there was no evidence of any residents being supported with activities though the registered manager said each unit had their own arrangements for Easter celebrations. This is discussed later in the report. One area of the home was not odour free on the day of the inspection, and the inspector also highlighted some food storage issues; these matters were discussed with the registered manager and also detailed later in the report. A complaint was made to CSCI since the last inspection and details are contained later in the report. There is also a Protection of Vulnerable Adults matter pending and the outcome of this may be relevant for the next report. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 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. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 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 Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 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): 1,3 and 6 Prospective residents have sufficient information to make an informed choice about the suitability of Brockhurst. Resident’s needs are assessed prior to admission and those admitted for intermediate care are helped to maximise their independence and return home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pre-admission information available to residents is good and sets out information on the premises, ethos of the home and the care provided. Residents are given their own copies of these documents to keep in their rooms. Four residents files were examined and all had an assessment of their needs prior to admission. Three had community care assessments carried out by care managers and other relevant reports from professionals. The fourth resident had been admitted for intermediate care and had a different preadmission assessment of need, concentrating on promoting independence and Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 10 relearning skills needed to return home. Therapist’s input was noted and this clearly informed the plan for this resident’s return to independence. The resident confirmed that the service offered at Brockhurst was meeting her needs and said ‘the home is lovely – they are so nice. I’m really grateful for all they’ve done.’ Some issues regarding medicines and food storage on this unit are included under those Standards later in the report. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 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 and 10 Care plans have improved considerably during the year but further work needs to be done to ensure all resident’s health and social care needs and goals are thoroughly documented, met and reviewed in a timely fashion. Medication practices are generally good but more work must be done to fully safeguard residents. Residents feel they are treated with respect though further improvements will be needed to meet this standard in full. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans viewed had really improved over the last year and generally gave a good overview of needs, drawn up as a result of a comprehensive assessment carried out before and in the early weeks of admission. Residents confirmed that their needs were being met. However, not all were completely filled in nor reviewed in a timely fashion. One care plan was missing and the assessment of need for this resident wasn’t completed either. The night care section of the needs assessment was not completed yet the resident had been staying at the home for over three weeks. Not all residents had photographs on their care Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 12 plans. This is an ongoing project for Brockhurst and progress has been good considering the challenges of recruiting and retaining staff at this home. Two of the residents spoken to were recovering from bouts of ill health and both confirmed the assistance available to them at Brockhurst had been appropriate; they also commented favourably on the care and attention they had received. This home has built up good relationships with the local GP practices and was supported by the district nurses as well as the intermediate care team. Residents were supported by staff to maintain their personal hygiene and one commented how well staff helped her with her washing and dressing each morning. A nutritional screening tool had been obtained by the home and the inspector passed on recently published information on nutrition in care homes from CSCI. Medication was checked on two units and found to be generally well administered; there were no gaps observed on Medication Administration Records (MARs) and storage of medication was tidy and well organised. Those who were administering some or all of their own medication had risk assessments in place. However, there were a number of minor shortfalls. The independence unit had medication in the locked cupboard that belonged to residents who had already gone home; it was unclear whether these residents had got their full prescription medications with them at home. The staff member on duty had been away and was not able to comment of the discharge of the resident in question. A new resident had been admitted on the morning of the inspection but his medication etc was not arriving until after 2pm – it was not clear whether he had lunchtime medication, which might be missed as a result of these arrangements. Some concerns regarding medication, care staffing levels, and communication in this unit have been raised recently and are currently being reviewed. The inspector agreed to take advice regarding the use of dosette boxes on this unit which are filled by the staff rather than a pharmacist. More generally throughout the home residents who were self medicating did not all have lockable cupboards in which to keep their medicines, and the home must review it’s policy regarding only one person taking responsibility for copying medication information from original containers onto MAR sheets; the CSCI pharmacist has now advised that a second person, trained and competent to do medication, should be checking this. One unit had insufficient ‘baskets’ in the medicines cupboard and some sort of dividers may be more appropriate. Residents were observed to be treated with dignity and respect during the inspection and many commented positively on the way staff behaved towards them, one resident volunteering; ‘They treat me well.’ Not all residents had a lockable space for their personal use and the manager said this would be dealt Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 13 with immediately; this appeared to be where some residents had moved rooms and the keys to the lockable cabinet in each room had not been passed on. This is mentioned under Standard 24. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 14 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 and 15 Residents had some mixed views about the activities and food at this home. Arrangements for visitors and community involvement, and opportunities to exercise choice and control, were good. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Daily routines seem to suit residents and where residents have expressed alternative preferences, the home tries to tailor the current arrangements. This is most noticeable with arrangements for meals and food, and this is documented in resident’s meeting notes. Brockhurst is arranged to encourage sociability and small groups of residents were observed to be chatting together, some others were reading, and the staff member on one unit was seen to be actively engaging with those residents who had chosen to sit in the lounge. This home employs an activities co-ordinator and much effort has been put into providing suitable activities. However, during the recent absence of this staff member the activities appeared to have declined. On the day of the unannounced inspection there were no apparent activities involving staff supporting residents. At least one Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 15 unit had a TV on, which no one appeared to be watching. Staff on the units, with one exception, appeared to be engaged in work on the unit such as emptying and filling the dishwasher, medication administration and making drinks – but residents did not appear to be helping with or involved in these tasks. Of those residents who commented on the activities some were unenthusiastic about the range and amount of activities and this area needs to be reviewed. Family and visitors are welcomed at Brockhurst and the family of one resident who had passed away recently had a number of good things to say about this home. They had clearly been involved in the care of their relative and they said any concerns or comments they had raised were taken seriously and acted upon. There does appear to be opportunities for residents to exercise choice and control over their lives at Brockhurst. Rooms were observed to be very personalised, and the manager said that the communal areas had had resident input into the choice of furnishings and colour of the décor. Most units had one or two more confident and outspoken residents who got involved in issues which they felt needed attention, on behalf of the others. Residents meetings were a further opportunity to highlight any concerns though only a small percentage of residents attended. On the day of the inspection the main meal of roast pork and fresh vegetables was observed on one unit and it received very positive comments. It looked appetising and was served with two fresh vegetables. The dining areas were nicely set out with napkins, tablecloths and fresh flowers. Residents had a choice of fruit juices or water to drink with their meals. In addition, one resident who had previously complained that his food was cold because it was served on cold plates, said he was now satisfied that this problem had been overcome after raising the matter with the deputy manager. Resident’s comments on the food were mixed, and a number had concerns which were highlighted to the manager. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 16 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 and 18 Complaints and protection of vulnerable adults matters are taken seriously at Brockhurst and this safeguards residents. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Brockhurst uses the Surrey County Council complaints procedure and residents can either use this, or raise matters formally or informally with senior staff. There was evidence from speaking to residents that they knew how to raise concerns and with whom. Two complaints were received by Brockhurst since the last inspection. The first was dealt with satisfactorily as confirmed in discussions between the relative who had raised the matter, and the inspector. A second complaint was referred to a specialist in the community for a response. One formal complaint had been received at CSCI since the last inspection and investigated by the Commission. The complaint concerned lack of suitably trained staff and concerns for resident’s safety. The investigation concluded that though some aspects of the complaint were upheld, e.g. some non-care staff were absent due to unforeseen circumstances, and there is a high usage of agency staff at this home, residents were not found to be at risk. Concerns regarding the safe administration of medication proved to be unfounded and those who had administered medication on that day had received training. Some related issues raised informally by a member of staff during the Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 17 inspection were, with permission, passed to the manager who will have further discussions with the person concerned. A number of written commendations had also been received from both residents and their relatives, mainly thanking the care team. The home has its own up-to-date copy of the Surrey Multi-agency procedures for the protection of vulnerable adults, and issues concerning these matters have been properly raised by the home in the past. A matter raised on one of the units recently is currently being investigated and CSCI will be kept informed of its progress. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 18 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): 19,24 and 26 Brockhurst provides a safe and well-maintained environment for the enjoyment of residents. Residents have comfortable bedrooms and many of their own possessions. The home is clean and hygienic throughout with only one small area needing attention in this regard. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The standard of the environment continues to improve at Brockhurst and staff work hard to provide a homely ambience for residents. The minor maintenance matters highlighted at the last inspection had been rectified. Residents commented very favourably on their bedrooms in particular. The staff at Brockhurst carry out some of the decorating themselves, and some residents said their son’s had assisted with redecorating their rooms. Bedrooms were personalised and comfortable and those who had recently had their rooms decorated were particularly keen to show the inspector what had Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 19 been done. The bathrooms and toilets were also nicely decorated and wellchosen accessories had been added. Two residents who had recently moved rooms had not yet been given the keys to the lockable cabinet in their new room; the manager said she would deal with this as a matter of urgency. Generally, the home was clean and fragrant throughout, especially the toilet areas. Due to an accident, one toilet needed attention during the inspection and the member of staff on that unit dealt with this quickly and discreetly. Also one area of a lounge was not completely odour-free and this was discussed with the manager. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 20 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 and 30. Resident’s needs are being met but the high usage of agency staff is a cause for concern and comment by some residents and staff. Residents are protected by the homes recruitment policies and staff are trained to do the work they are given. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Brockhurst now uses the Residential Forum Matrix to calculate staff to resident ratios. The staff rota confirms the number of staff on duty per unit throughout the day and night. There are additional staff at peak times and a chef and domestic staff are employed to perform non-care activities. Some concern was expressed about staff having to move from one unit to another for extended periods to assist with personal care and moving and handling residents; this was taking them away from the residents and duties on their original unit. Staff also swap around if the unit does not have a staff member on duty who can administer medication. One unit was highlighted as particularly ‘heavy’ and the manager was asked to review whether extra staff are needed on this unit due to the higher needs of residents. There are also a significantly high number of falls, many unwitnessed, at this home; the final section of the report discusses this in more detail. The manager said the increasing frailty of residents is at least partly to blame for these incidents but a review of staffing levels may also be worthwhile. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 21 Brockhurst, as stated in the last report, exceeds the 50 minimum of staff with NVQ2 or above. Though there is a very high usage of agency staff, in excess of 70 at times, many of these staff have agreed to work regular hours at Brockhurst and some have been working there for years. They are offered training with the permanent staff and this includes medication training. The lack of permanent staff was raised as an issue during the inspection. Some relatives commented that regular staff had suddenly left, and some residents mentioned they missed the regular staff when they were not working. This was also highlighted in the last report. Brockhurst continues to try to recruit permanent staff and were interviewing for care staff on the day of the inspection. Several different members of staff commented on the shortage of staff, as they perceived it; the manager said Brockhurst now has more staff than at any point in the past. Recruitment at Brockhurst follows the Surrey County Council policies and procedures and staff records checked on the day of the inspection had application forms, two written references, and CRB checks in place. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 22 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): 31,33,35 and 38 The manager discharges her responsibilities in a professional manner and the home is run in the best interests of residents though further work is needed to meet this Standard in full. Resident’s financial interests are safeguarded and the health and safety of residents are promoted. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current manager is competent and very experienced in managing care homes for older people. She continues to update her training and is knowledgeable about the needs of older people and those with dementia. There are clear lines of accountability within the home and this is evident from speaking with both staff and residents. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 23 The home is run in the interests of residents and there are a number of ways in which they can have an input to the service they receive. Resident’s interviewed were able to speak up for themselves and gave examples of when they had done so, sometimes on behalf of other residents. Residents meetings gave an opportunity for any resident to be involved though few take this opportunity. In addition, unit inspections provide an opportunity to look at specific issues on each unit and notes of these inspections were also seen. The home has monthly Regulation 26 visits by a person appointed by the Surrey County Council (SCC) and this covers all areas of relevance to residents and includes their input where appropriate. The home also has ad hoc audits such as the dementia care audit reported on at the last inspection. However, the SCC internal audit of care, which involves pairs of care homes assessing each other on a cyclical basis, is still behind schedule. The sister home to Brockhurst has been unable to participate in these arrangements for some time and therefore this requirement is still outstanding from the last inspection. The registered manager said they hoped to re-start the process in May/June 2006. The home also needs to up-date its development plan for the home and identify which other issues listed in Standard 33 need further work. Resident’s mainly look after their own money but those who need to access their own money whilst at the home are able to do so. Residents are safeguarded as this home uses the same Surrey County Council financial arrangements which are in place throughout their care homes. A non-care member of staff is responsible for the day to day running of this scheme. Health and safety continues to improve at this home. A number of issues were checked during the inspection and were satisfactory including all the medicine cupboards and hazardous substances cupboards on the units were found to be locked, units were clean and tidy with no obvious hazards to staff or residents, and accident records were checked and found to be centrally kept and correctly completed. The inspector noted that food cupboards on one unit had containers of unlabelled food, and some items, including butter, should have been stored in a refrigerator. The refrigerator contained a few items which were neither labelled nor covered. The manager was asked to review these practices. The hairdressing salon was visited during the inspection and the inspector raised some concerns with the manager about frail residents being left under hairdryers unattended. Brockhurst continues to have a high number of incidents reportable under Regulation 37 arrangements. Over 50 such incidents, including many unwitnessed falls, have occurred since the last inspection seven months ago. At the previous inspection the matter was discussed and it was agreed that a review of what was reportable under Regulation 37 was carried out, with staff using their own professional judgement about what was relevant. It was also Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 24 agreed that a regular falls audit would be carried out and used as a tool to identify anyone particularly susceptible to falling; remedial action could then be directed towards those most at risk. The manager has carried out this work and the number of falls has reduced considerably over the previous 6 months. The manager believes that the numbers are still high because of the increasing frailty of the residents at this home. The home has also put staff on falls training which alerts them to the prevention of falls, as well as helping them to identify residents needing to be to be seen by the falls prevention team. Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 25 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 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15(1) Requirement The work on completing care plans must continue until all residents have a fully completed and up to date plan of care. Outstanding from 20/11/05. All residents who are selfadministering medication must have a locked cabinet in which to store the medication. The manager must review the procedure for handwriting medications onto medication administration records as discussed during the inspection. The manager must review the communication and arrangements surrounding medication for those entering and being discharged from the independence unit as outlined in the report. One unit had an area which was not odour free (as discussed with the manager) and this must be rectified as soon as possible. The manager must review staffing levels with particular regard to; • the unit where residents DS0000033514.V288693.R02.S.doc Timescale for action 12/06/06 2. OP9 13(2) 13/04/06 3. OP9 13(2) 19/04/06 4. OP26 16(2)(k) 13/04/06 5. OP27 18(1)(a) 12/05/06 Brockhurst Version 5.1 Page 27 6. OP33 24(1)(a) 7. OP38 13(4)(a) (b)(c) are very physically frail, the high number of falls in the home generally • the high number of agency staff employed in the home. The Council’s own internal quality assurance processes must be restarted and the manager ensure Brockhurst complies with all elements of Standard 33. Outstanding from 20/11/05. The storage of food items in cupboards and fridges must be reviewed as outlined in the report. • 12/06/06 13/04/06 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. Refer to Standard OP9 Good Practice Recommendations All residents should have a photograph on their medication file in line with the home’s policy on the safe administration of medicines. The manager should review the current arrangements for activities and consult with all residents on this matter. In view of the mixed comments regarding food, the manager should consult all residents on what improvements, if any, need to be made. Residents should each have their own lockable cabinet or drawer in their own bedroom. The manager should review arrangements for the hairdressing salon as discussed during the inspection. The manager should continue to monitor the level and nature of falls and accidents within the home with a view reducing these further. 2. 3. 4. 5. 6. OP12 OP15 OP24 OP38 OP38 Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Brockhurst DS0000033514.V288693.R02.S.doc Version 5.1 Page 29 - 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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