Inspection on 19/08/08 for Brockshill Woodlands

This inspection was carried out on 19th August 2008.

CSCI found this care home to be providing an Adequate service.

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

Brockshill Woodlands 04/03/10

Brockshill Woodlands 01/03/10

Brockshill Woodlands 29/12/09

Brockshill Woodlands 22/11/07

Brockshill Woodlands 03/01/07

Brockshill Woodlands 23/11/05

Brockshill Woodlands 20/06/05

Brockshill Woodlands 26/11/04

Brockshill Woodlands 09/09/04

Brockshill Woodlands 25/03/04

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Trevayler Residential Care Home

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Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Brockshill Woodlands Briar Walk Oadby Leicestershire LE2 5UF Lead Inspector Debbie Williams Unannounced Inspection 19th August 2008 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 Brockshill Woodlands DS0000001814.V370813.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. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brockshill Woodlands Address Briar Walk Oadby Leicestershire LE2 5UF 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) 0116 2716014 0116 2716014 Prime Life Ltd Vacant Care Home 30 Category(ies) of Dementia - over 65 years of age (27), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (30) Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Brockshill Woodlands care home is registered to provide personal care to male and female service users who fall within the following categories: Old age, not falling within any other category (OP) 30. Only persons falling within the category OP should be accommodated in the two single bedroom bungalows situated in the grounds of Brockshill Woodlands. No one falling within the category of DE(E) should be accommodated in Brockshill Woodlands when there are already 27 persons accommodated under the category of DE(E). Persons should only be accommodated in the double-bedded bungalow situated in the grounds of Brockshill Woodlands under categories OP, and DE(E). A maximum of one person falling within the category DE(E) should be accommodated at any one time. No one falling within category MD(E) should be accommodated at Brockshill Woodlands when there are already five persons of the category MD(E) accommodated in the home. No persons should be accommodated in the double-bedded bungalow situated in the grounds of Brockshill Woodlands unless they are an established co-habiting couple, or have an established friendship/relationship, prior to being accommodated in the bungalow. The maximum number of persons to be accommodated at Brockshill Woodlands is 30. 22nd November 2007 5. 6. 7. Date of last inspection Brief Description of the Service: Brockshill Woodlands is a care home providing personal care and accommodation for up to thirty older persons who may have additional needs, which may include Mental Disorder or Dementia. Accommodation comprises of the main care home and three self-contained bungalows; bedrooms are both single and shared. Parking for visitors can be found to the front of the home. Brockshill Woodlands is located in a residential area of Oadby. Communal areas consist of a dining room and three lounges, and are located on the ground floor, with access to the garden from the lounge to the rear of the home. Bedroom and bathing facilities are located on the ground and first floor. Information is located on site detailing the range of services offered, which includes the Statement of Purpose and Service User Guide. Copies of the Commission for Social Care Inspection’s Inspection Reports are available by Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 5 request at Brockshill Woodlands. The fees at Brockshill Woodlands range from £327.00 - £470 per week. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, discussion, where possible, with them, their relatives and care staff and observation of care practices. Because many people living at the home have some communication difficulties, discussion with them about the care they receive was limited. Two residents, two relatives and three staff members were spoken with and observation of care practices and staff interaction was used. What the service does well: What has improved since the last inspection? Since the last inspection the acting manager has changed staff routines to enable better monitoring of people living in the home in order to reduce the incidence of falls and accidents. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 7 One senior carer said that people living in the home are offered a minimum of two baths/showers a week and every effort is made to provide more depending on individual preference. 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. Brockshill Woodlands DS0000001814.V370813.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 Brockshill Woodlands DS0000001814.V370813.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): Standards 1,2,3 and 4. (Standard 6 is not applicable to this service). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to make an informed choice and have their needs assessed before moving in to the home. EVIDENCE: A Statement of Purpose and brochure is provided to all people considering moving into the home. Information provided sets out the provider’s philosophy and the type of service and accommodation provided, this enables people to make an informed choice before deciding to move into the home. Relatives spoken with at the time of this inspection confirmed that they had received this information. An additional pamphlet is also provided and this gives people information about dementia and the advocacy services available to them. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 10 A needs assessment is undertaken before people move into the home. This is undertaken by the home’s acting manager and is carried out to ensure the service is able to meet the prospective residents needs. A contract of terms and conditions is provided to all privately funded residents. A recommendation was made that the terms and conditions also be supplied to people receiving funding, this would ensure that all people living at the home are made aware of the terms and conditions of residency. Assessment records for case tracked residents were seen and these were found to be comprehensive. Needs assessments also included risk assessments and actions to take to minimise risk. An individual care plan was then generated based on assessed needs. At the time of this inspection there were no people from an ethnic minority community living in the home. The acting manager said that the statement of Purpose and accompanying brochure could be provided in other formats or languages upon request. The accompanying brochure also sets out a charter of ‘rights’ that people living in the home can expect to have upheld. This charter also states that all ‘social, emotional, religious, cultural, political and sexual needs will be accepted and respected’. The service is registered to accommodate people with dementia and mental health needs. While staff on duty on the day of this inspection were seen interacting with residents in a positive way, not all staff had received training in the areas of dementia and mental health. A requirement was made regarding this. Brockshill Woodlands DS0000001814.V370813.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): Standards 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have their personal support and care needs clearly identified and are treated with respect. Procedures for the management of medication could be improved in order to provide better protection for people living in the home. EVIDENCE: Individual care plans were seen for case tracked residents and these addressed all assessed needs including social and psychological needs. Social services care plans were also in place where this was applicable. Care plans provided staff with clear instructions of the actions they must take to meet individual needs. A key worker system was in place and the manager held care-planning meeting with key workers to discuss their resident’s individual needs. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 12 Evidence was seen within care records of consultation with healthcare professionals such as community nurses and GP’s. Residents and relatives spoken with also confirmed that staff would consult with a GP whenever this was required. Medication administration records and storage areas were seen. Some medicines, which were no longer required or only required occasionally, were still written up to be administered every day. The audit records for controlled medication were found to be incorrect and this demonstrated that staff were not counting medication correctly. One person who was prescribed medication with a potentially sedating affect needed a review of this prescription in order to ensure this medication was still appropriate for their needs. Staff responsible for administering medication had been assessed and had received training in this area. Requirements were made regarding the safe handling and administration of medication. Two residents spoken with felt staff managed their medication effectively and correctly. Interaction observed between staff and residents appeared positive and respectful. Staff were heard offering appropriate reassurance and support to residents. Two residents and two relatives spoken with felt that staff did treat residents with respect and maintained their privacy and dignity. However, relatives spoken with did identify that on occasion their relative was dressed in clothes belonging to other residents and therefore this did not promote the dignity of this person. The acting manager said that separate laundry staff had been employed in order to prevent this happening again. Brockshill Woodlands DS0000001814.V370813.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): Standards 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. People living in the home are encouraged to make choices about daily living and to maintain contact with their family and friends. EVIDENCE: Individual care plans address peoples social needs and preferences. There is a range of activities being provided and these included trips outside of the home. Information about the activities on offer each month is available at the home. The acting manager said that family and friends were encouraged to take part in activities such as family evenings where a buffet is provided. Residents and relatives spoken with said they happy with the range and frequency of activities provided and said there were no restrictions on visiting. One staff member spoken with described how people’s autonomy and choice was promoted. This included encouraging people to choose how to spend their Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 14 day, what time to get up or go to bed etc and what clothes to wear. People were also asked to specify how many times a week they would like a bath or shower. Two residents spoken with confirmed they could make choices and choose how to spend their day. Where possible, residents were able to help with domestic tasks such as setting tables or folding tea towels if they wished to. The lunchtime meal was served during this inspection and the meal appeared appetizing and nutritious. People spoken with said they were happy with the quality and quantity of meals provided. Meals are brought into the home form the provider’s central kitchen. People are offered a choice at every meal. Menu records were seen and confirmed this. Staff were seen assisting residents with their lunchtime meal in a sensitive and appropriate manner. Staff have access to the kitchen at all times and can provide drinks and snacks on request. There were no specific special diets being provided for during this inspection but the acting manager said these would be provided where needed. Brockshill Woodlands DS0000001814.V370813.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): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints and adult protection policies and procedures are in place to minimise risk for people living in the home. People would be better protected if all staff received training in this area. EVIDENCE: A copy of all complaints received is maintained. The provider’s complaints procedure is included with the Statement of Purpose. People spoken with said they would feel happy to make a compliant to the acting manager. Staff spoken with also said they could raise any concerns with the management team and these would be taken seriously and acted upon. Brockshill Woodlands has a Prevention/Detection of Abuse Policy and Procedure, which outlines the responsibilities of the individual and organisations in responding to or alerting to possible abuse. A copy of National policy and guidelines ‘No Secrets’ was also available in the office. Two staff members spoken with had not received any challenging safeguarding adults training or training about the management of challenging behaviour. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 16 A requirement was made about this. Staff must receive this training in order to minimise risk to people living in the home. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a comfortable and homely environment. People would be better protected if Fire Service requirements were always adhered to. EVIDENCE: Brockshill Woodlands is a large period property, set within a residential area of Oadby, in addition to the home it self, there are three self-contained bungalows. A partial tour of the premises was undertaken, we looked at communal areas and at the private accommodation of case tracked residents. There is a choice of lounges and a dining room. On the day of this inspection all areas seen appeared clean and tidy. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 18 The private rooms of people living in the home were personalised with people’s own possessions and appeared comfortable and homely. An Environmental Health Officer had recently visited the home and made some requirements. Not all records required to comply with fire service regulations were being maintained, there were gaps for the weekly testing of fire alarms. A requirement was made regarding this. A separate laundry area was provided for people’s personal laundry. Separate staff had recently been employed to work in the laundry in order to address some problems with people’s clothes being put in the wrong rooms. Staff had received infection control training and were aware of the procedures they needed to follow in order to minimise the risk of cross infection. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 19 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. People are looked after by competent staff and protected by good recruitment procedures. EVIDENCE: Staffing numbers were sufficient to meet the needs of people living in the home. An ongoing programme of staff training and development was in place. This included National Vocational Qualification and induction training. All mandatory health and safety training was provided to staff and this promoted safety for people living and working in the home. Not all staff had received protection of vulnerable adults or management of challenging behaviour training; a requirement was made regarding this. Recruitment procedures were robust. All necessary references and checks were in place to ensure that staff were suitable for working at the home and that people living at the home were protected. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 20 Staff spoken with confirmed they had received induction training and felt they received the training and support they needed to do their jobs. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 21 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): Standards 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health safety and welfare of people living in the home is promoted and protected. EVIDENCE: At the time of this inspection there was an acting manager running the home. The acting manager is in the process of applying for registration with the CSCI. Staff spoken with said the acting manager was supportive and approachable. An in house quality assurance programme was in place. This included six monthly audits carried out by members of the senior management team and Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 22 quality assurance questionnaires being given to residents and their families/friends, this enables the provider to assess how the service is achieving goals for people living in the home. Residents/relatives meeting are also held. Audits are also used to assess and minimise risk, the acting manager explained how auditing accidents and falls lead to staff routines being changed to enable better monitoring of people living in the home. Records are maintained for all transactions regarding resident’s personal money, two signatures are obtained for every transaction and receipts are retained. This minimises the risk of financial abuse for people living in the home. Records were seen of routine maintenance and servicing, these were up to date apart from weekly fire alarm testing which had not been tested since the 4th of August 2008. Hot water is checked every month to ensure it at safe temperatures for people living at the home. Staff had received all necessary health and safety training such as moving and handling, fire safety and food hygiene and were aware of safe working procedures to protect themselves and people living in the home from harm. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 23 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 2 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 2 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 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 24 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 OP4 Regulation 18 Requirement All care staff should receive training in caring for people with dementia and mental health needs. This is to ensure that all staff have the skills to meet the needs of people living in the home. The registered provider shall make arrangements for the recording, handling, safekeeping and safe administration of medicines received into the care home. This is with particular regard to review of medication prescribed and ensuring that administration records and medicine audits are accurate. People living in the home must have their privacy and dignity maintained at all times. This is with particular regard to personal property and wearing their own clothes. Timescale for action 30/11/08 2 OP9 13 19/08/08 3 OP10 12 19/08/08 Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 25 4. OP18 12 All care staff should receive training regarding the management of challenging behaviour and safeguarding adults’ policies and procedures, this is to minimise risk to people living in the home. Fire alarms must be tested weekly as required by the fire service. 30/11/08 5 OP19 23 19/08/08 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 OP1 Good Practice Recommendations All residents living in the home should be provided with the terms and conditions of residency. Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Brockshill Woodlands DS0000001814.V370813.R01.S.doc Version 5.2 Page 27 - 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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