Inspection on 13/06/07 for Brockhurst

This inspection was carried out on 13th June 2007.

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

Brockhurst 30/09/08

Brockhurst 12/04/06

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 Mary Williamson Unannounced Inspection 13th June 2007 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.V341596.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. Brockhurst DS0000033514.V341596.R01.S.doc Version 5.2 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 tina.davis@surreycc.gov.uk 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.V341596.R01.S.doc Version 5.2 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. 12th April 2006 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.V341596.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of a key inspection and was unannounced. The inspection took place over five hours. Mary Williamson Regulation Inspector carried out the inspection. The Registered Manager Tina Davis represented the establishment. A tour of the premises was undertaken, and a number of records relating to the care of the residents and the management of the home were examined. Discussions were held with residents both individually and in small groups. They were all willing to talk and share their experiences about living in the home. Feedback was generally favourable and complimentary of the home and the staff. There were various activities taking place on the individual units. Residents were sitting in small groups talking, watching television, reading the daily newspaper, and visiting each other in their rooms. One to one activity, for example walks in the garden, was also taking place. A group of residents were chatting in a group waiting outside the hairdressing salon for their appointments. The kitchen was visited and the chef spoken to. Lunch was observed and the choice of menu was appetising, and wholesome. Residents were generally satisfied with the food offered. There was opportunity to talk with staff individually on various units. They were able to confirm training they had undertaken and could demonstrate individual needs and how they support these. Recruitment procedures were sampled and were satisfactory. Staff training and development were explored and demonstrated that all staff have appropriate training to undertake the care outlined in individual care plans. The manager completed the Annual Quality Assurance Assessment (AQAA) prior to the inspection. The Commission for Social Care Inspection would like to thank the residents, staff and management for their help and hospitality during the inspection. Brockhurst DS0000033514.V341596.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? All the requirements and recommendations from the previous inspection have either been met or partially met. Care plans are in place and up to date. There are facilities in place to accommodate residents who self-medicate. Mal odour has been addressed and a new carpet provided in the affected area. Staffing arrangements have been rearranged to target the issues outlined in the last inspection, including falls and the use of agency staff. Photographs have been provided in Medication recording charts. Residents have their own lockable unit in their bedroom. A detailed analysis of falls in the home is undertaken by the manager monthly and discussed with the nurse practitioner. Appropriate referrals are then made according to individual needs. Brockhurst DS0000033514.V341596.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brockhurst DS0000033514.V341596.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 Brockhurst DS0000033514.V341596.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have sufficient information available to help them make a choice about living in the home. Needs assessments and contracts of occupancy are in place. EVIDENCE: The Statement of Purpose was seen and includes all the relevant information necessary for prospective residents and their relatives to make an informed choice about living in the home. There is a copy of this document available in the reception area, which is easily accessible. All prospective residents have a needs assessment undertaken prior to admission to the home. The manager carries out this assessment, or a member of the senior care team, to establish the suitability of the placement and assessed needs can be met. Four assessments were randomly sampled and were informative, detailed, and well maintained. These are reviewed on a regular basis. Contracts of occupancy are in place between Surrey County Council and the residents. These outline the room to be occupied and the level of support Brockhurst DS0000033514.V341596.R01.S.doc Version 5.2 Page 10 required. They do not outline the level of fees charged. Residents or a designated representative sign these contracts. The home does not currently provide intermediate care. Brockhurst DS0000033514.V341596.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are being met as outlined in individual care plans. Medication practice safeguards the residents, who are also treated with dignity and respect. EVIDENCE: Each resident has a care plan in place and four of these were randomly sampled. These are well written based on information gathered from the needs assessment, input from the residents and their relatives and any other relevant medical reports. Care plans are signed and reviewed on a regular basis. The arrangements in place to meet the health needs of the residents are good. All residents are registered with a local GP practice. The home also has the support of a nurse practitioner, who visits the home frequently to advise on good practice, review medication regimes and pain relief control. She will also undertake assessments of health needs and refer to specialist consultants for further treatment. The home also has the support of the district nursing team who currently visit one resident. Chiropody, dental and optical care are also available on a regular basis. Brockhurst DS0000033514.V341596.R01.S.doc Version 5.2 Page 12 The home has a medication policy in place and all staff who administer medication are familiar with this policy. Medication practice was observed on Daisy Unit and Camellia Unit. Lloyds Pharmacy supplies the medication to the home mainly in blister pack format. They also undertake periodic audits of medication. The medication recording charts were seen and are well maintained. It was recommended at the last inspection that residents’ photographs should be introduced to the front of the medication charts, and these are now in place. Currently there are no residents in the home that self-medicate; however facilities are available to facilitate this practice if required. The home maintains an audit trail of all medication entering and leaving the home. All staff undertake medication training and safe administration practice prior to undertaking this procedure and evidence of this training was seen on staff training files. Brockhurst DS0000033514.V341596.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social and recreational activities satisfy the majority of residents and there are good community and family links. The catering arrangements are very good and residents’ dietary needs are being met. EVIDENCE: Individual activity programmes are in place, which vary in quality and choice. Some of the activities offered include, letter writing, knitting, sewing, card games, board games, beauty treatments, crossword puzzles, and music. There was a variety of activities taking place on individual units. Some residents were sitting in the lounge talking and watching television, others reading the newspaper, two residents were visiting each other in their bedrooms and there was a group of residents sitting chatting outside the hairdressing salon while waiting for their hair appointments. The inspector observed several episodes of one to one involvement, for example a resident walking in the garden with a staff member picking flowers, one resident helping to dry the crockery after lunch under the supervision of a staff member, one resident helping to prepare the table for lunch. Brockhurst DS0000033514.V341596.R01.S.doc Version 5.2 Page 14 The manager demonstrated the safe garden project to the inspector. This provides residents the freedom to wander in a large garden easily accessible from all units. It is well equipped with furniture and flower tubs. Several residents commented on how they enjoy this facility. Other residents stated that there was not enough opportunity to go shopping or on day trips. This was discussed with the manager who explained that currently the activity coordinator post is vacant and that every effort was being made to recruit to the post, and to reinstate outings. Family links are maintained and visitors are welcome into the home at any reasonable time. One resident was looking forward to her family visiting during the afternoon. There was evidence of relative participation in care planning and good to note their contribution to the social history element in dementia care planning. Relatives are also involved in meetings and attending home events, for example special celebrations and a charity fund raising walk. Spiritual needs are recognised and visits from various clergy are arranged. There is a Church of England Holy Communion Service arranged monthly in the main communal area and a Roman Catholic Holy Communion Service on request. The catering arrangements are well organised by the chef who has been employed in the home for several years. He organises the menus over a fourweek cycle. These are well balanced and varied. Lunch was observed during the inspection and included roast chicken and bacon, a selection of fresh vegetables and potatoes, followed by home made fruit trifle. The residents who made comments stated that the food was “very nice” and “the meals are excellent”. Residents are offered an alternative to facilitate choice. Snacks and drinks are available throughout the day. The kitchen was visited and was clean and orderly. All the required documentation and records are in place in accordance with food hygiene. The last Environmental Health inspection was February 2006 when a food safety aware was issued. Themed evenings are also organised by staff. Residents spoke of an Indian evening the previous week when staff cooked for the residents and there are plans for an African evening next month. Brockhurst DS0000033514.V341596.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s complaints procedure and abuse awareness policy in place. EVIDENCE: The home has a complaints procedure in place and all residents have access to a copy of this, which is included in the Service User Guide. Residents were aware of this procedure and stated that if they were unhappy with a situation they would discuss this with the manager. There have been no complaints since the last inspection. There is an abuse awareness policy in place and during conversation with several staff members they were all aware of this policy. They were able to confirm what action they would take if an incident of abuse occurred. There was also evidence on staff training and development files that abuse awareness training had taken place. The home also has a copy of Surrey’s Multi Agency Policies and Procedures on Safeguarding Vulnerable Adults in place and training is also ongoing in these procedures. Brockhurst DS0000033514.V341596.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well- maintained and comfortable environment, which meets their individual and collective needs. The standard of cleanliness is very good. EVIDENCE: The home is currently undergoing refurbishment and there is one unit closed to facilitate this. Accommodation is arranged over seven units on two floors. Each unit has its own lounge and dining area overlooking the safe garden. These areas are comfortable, well furnished and homely. The manager stated that all individual and communal accommodation was due to be redecorated. Bedrooms are of single occupancy and have been personalised to reflect individual personalities. Several residents stated that they liked their bedrooms. They also stated that they like to visit each other in their rooms for a chat. All bedrooms now have lockable and secure facilities in place for personal belongings. Brockhurst DS0000033514.V341596.R01.S.doc Version 5.2 Page 17 The standard of cleanliness is good and well maintained by the housekeeping team. The laundry facilities are also satisfactory to meet the requirements of the home. Brockhurst DS0000033514.V341596.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are currently being met. Residents are protected by the home’s recruitment policy and the home is also committed to the training and development of staff. EVIDENCE: Staff recruitment has been an issue at Brockhurst for some time and the home took the decision four months ago to suspend admissions to the home until this has been resolved. The home is registered for forty-six residents and there are currently thirty-four residents living there. There has been a significant reduction in the use of agency staffing the home. The agency staff working in the home have been there for several years. The staff duty rota was discussed with the manager and the number and skill mix of staff on duty was sufficient to meet the current assessed needs of residents. Staff training and development are ongoing with 70 of staff having achieved NVQ Level 2. All staff undertake induction training, which is organised by Surrey County Council. This is undertaken during a six- month probation period. The agency staff working in the home also undertake mandatory training, which is also provided by Surrey County Council. During discussion with staff they confirmed various training courses they had attended. Recruitment at Brockhurst follows Surrey County Council policies and procedures and staff records checked on the day of the inspection contained all the required documentation including an application form, two written Brockhurst DS0000033514.V341596.R01.S.doc Version 5.2 Page 19 references, an employment history and a CRB (Criminal Records Bureau) disclosure in place. Brockhurst DS0000033514.V341596.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed in the best interest of the residents. Residents’ financial interests are safeguarded and the health and safety of residents are promoted. EVIDENCE: The home is very well managed. The registered manager has been in post for the past seven years, and has several years experience in the provision of care for older people. She has an NVQ level 4, and is also an NVQ assessor. Her deputy manager also has an NVQ Level 4 qualification and the experience necessary to manage the home effectively. There are also eight senior care staff for managerial support. Residents and staff spoken to all felt well supported by the management structure within the home. Brockhurst DS0000033514.V341596.R01.S.doc Version 5.2 Page 21 There are robust systems in place to monitor quality assurance. The service manager undertakes monthly monitoring Regulation 26 visits. Residents meetings, relative meetings, individual unit meetings for staff and residents, and unit improvement plans take place and the feedback acted upon. Resident surveys, and relative surveys are undertaken and information retained on file. There is a suggestion box in the reception area for comments. The catering department also undertake quality surveys for food, and the standard of catering in general. The home also maintains a compliment and “thank you” file, which contains many favourable thank you letters and cards. Residents’ financial interests are safeguarded by the home’s financial procedures. There is a bursar in post who oversees the financial transactions for the home. No staff member acts as appointee for residents. Small amounts of money are held by the home on behalf of the residents who are unable to manage their own finances. This is used mainly to pay for hairdressing, chiropody and any sundries the residents may wish to purchase. A wide range of health and safety policies and procedures was observed throughout the inspection. All staff receive health and safety training during induction training which includes, first aid, manual handling, food hygiene, risk awareness, fire safety and COSHH. This training is updated frequently. All staff receive formal supervision at least every six to eight weeks. There is a supervision rota displayed in the manager’s office indicating dates and who is undertaking the session. Supervision notes are kept on file. Risk assessments are in place for all identified risks and safe working practice. Accidents and incidents are recorded correctly. The amount of falls and reportable incidents has reduced significantly since the last inspection. Following a discussion with the manager she stated that a falls analysis is undertaken each month to monitor the action she needs to take. This is then discussed with the nurse practitioner and appropriate referrals made either to the falls clinic, physiotherapist, or the consultant psychiatrist to review medication regimes. This was noted to be very good practice. The management of fire safety procedures is good. The fire alarms are tested weekly and recorded. There is a contract in place for the maintenance of the fire alarms, emergency lighting and fire fighting equipment. Fire safety training is undertaken annually. Brockhurst DS0000033514.V341596.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 3 3 X X 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 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Brockhurst DS0000033514.V341596.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brockhurst DS0000033514.V341596.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brockhurst DS0000033514.V341596.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. 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