Inspection on 20/06/05 for Brockshill Woodlands

This inspection was carried out on 20th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Brockshill Woodlands 04/03/10

Brockshill Woodlands 01/03/10

Brockshill Woodlands 29/12/09

Brockshill Woodlands 19/08/08

Brockshill Woodlands 22/11/07

Brockshill Woodlands 03/01/07

Brockshill Woodlands 23/11/05

Brockshill Woodlands 26/11/04

Brockshill Woodlands 09/09/04

Brockshill Woodlands 25/03/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Brockshill Woodlands Briar Walk Oadby Leicestershire LE2 5UF Lead Inspector Fiona Stephenson Unannounced 20 June 2005 09:30 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 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 C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Brockshill Woodlands Address Briar Walk Oadby Leicestershire LE2 5UF 0116 2716014 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Prime Life Limited Vacant Care Home 26 Category(ies) of DE(E) Dementia - over 65 (5) registration, with number MD(E) Mental Disorder - over 65 (5) of places OP Old Age (26) PD(E) Physical Disability - over 65 (2) Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26/11/04 Brief Description of the Service: Brockshill Woodlands is a residential care home for up to 26 older persons, some of whom have physical disabilities or mental health needs. The home is a large detached house with communal areas on the ground floor, including two large lounges, a through lounge and a dining room. Bedrooms are on the ground and first floor. It is situated near the centre of Oadby in Leicestershire. To the rear of the home is a secluded garden, which is wheelchair accessible. Off-road parking is available for visitors. Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on Monday 20th June from 09:30 to 15:30. The inspector focused the inspection on the outcomes for residents being cared for in the home. The main method used in the inspection was ‘case tracking’ which means that the Inspector selected four residents and tracked the care they received through looking at their records, observing their personal accommodation, talking with them and their relatives where possible, and observing care practices. Other files including health and safety files, and staffing files were also checked. Four residents, two members of staff, and three relatives were spoken with. One relatives comment card was received, the contents of which was discussed. What the service does well: The acting manager is working well in raising standards in the home, and has put in place good management systems. The home is clean, and tidy. Relatives and visitors are welcome in the home at all times of the day and evening. The acting manager has in a very short space of time, introduced good systems to identify and act upon residents needs. Care staff are observed to have a good rapport with residents. Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Management must ensure window restrictors are operational on the first floor, and that the side gate to the garden is not left open. Management must ensure an action plan is drawn up regarding the training and supervision of the member of staff identified during the inspection, whose recording of the administration of medication is not always accurate. Further improvements relating to care files could be introduced such as providing more detailed information relating to the daily reports of residents, and to ensure residents or their relatives sign the care plans. Staff’s knowledge of vulnerable adult procedures and whistle blowing procedures could be improved. Staff deployment and staff levels could be improved during the day by reducing the amount of time care staff spend on kitchen and laundry duty. Seating in the garden area could be made more comfortable for residents to encourage more use of the garden area. Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 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. Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 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 standard(s) 3 and 5 The home does not provide intermediate care therefore standard 6 is not applicable. Service users are satisfactorily having their needs assessed to ensure that when they enter the home, staff will be able to support them. EVIDENCE: The inspector checked the initial assessments undertaken and then linked these with the care plans. It was demonstrated through the care plans that needs were assessed correctly and residents’ needs are being met. Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 10 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 standard(s) 7,8,9,10,11 Health and personal care needs of residents are on the whole, well met; however some aspects of the administration of medication are less than satisfactory. EVIDENCE: Four residents files were checked. All had care plans which were being updated on a monthly basis and there were daily records of care, although information in the daily records mainly focused on staff’s responsibilities in meeting the care plan, and care plans were not signed by the residents or their relative. One member of staff now has responsibility for ensuring residents chiropody, eye care and dental care needs are being monitored, and improvements in this aspect of care were evident. The records relating to the administration of medication by one member of care staff are not satisfactory, with mistakes being noted on a few occasions. Other staff recorded medication administration well. Residents were observed to be treated with respect during the inspection, and relatives spoken with were very happy with the care given e.g. ‘I am very happy with my mother’s care. I was worried about how she’d settle as she has dementia, but I’m really pleased with how she’s settled and the care she’s been given’. Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 11 Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 12 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 standard(s) 12,13,14. Residents are provided with sufficient activities both within and outside the home to satisfy their social, religious and recreational interests and needs. EVIDENCE: There are regular trips out organised by management. On the day of inspection, residents were involved in a once a fortnight ‘chair aerobics’ session. Care notes demonstrated that resident’s religious needs were met by being provided with support in getting to church or having a minister attend the home. Relatives informed the inspector that they were welcomed at the home at any time during the day or evening. Records demonstrated that staff encourage residents to go out of the home to attend appointments and support them in retaining independence where they can. Residents currently do not have public transport tokens, and the new manager is looking into this issue. Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Complaints are taken seriously and acted upon well. Satisfactory measures are in place to protect residents from abuse. EVIDENCE: The complaints record showed two formal complaints had been made since the last inspection – both about the same issue. The record demonstrated that prompt action had been taken and relatives were satisfied with the outcome. In discussions with relatives they also indicated they would feel able to talk to the management if they had concerns. Staff files were checked to ensure Criminal Records Bureau clearance had been obtained, and these were in satisfactory order. Staff also have training relating to the protection of vulnerable adults. This was discussed with staff, and although they had a reasonable understanding of the processes, they would benefit from refresher training. Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 Generally, residents live in a safe and well-maintained environment. EVIDENCE: The inspector toured the building and looked at all communal areas and the majority of bedrooms. The acting manager had already identified areas in the home that needed further decoration, and floor coverings in some of the bedrooms that needed replacing with an action plan already being in place. Specialist equipment to further support staff in the moving and handling of residents has recently been purchased and training is in place to ensure the equipment is used well. The home is clean and pleasant, with comfortable indoor facilities. The garden is in good condition, however one resident commented that the garden seat wasn’t very comfy and that was why she never sat out in the garden. Whilst out in the garden, the inspector observed one of the first floor windows to be wide open and queried whether there were window restrictors being used. The manager informed the inspector that there should be window restrictors, but it was not evident one was being used on that occasion. The garden gate was also open. The acting manager, aware of Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 15 one resident’s risk to herself if leaving the premises without support from staff or relatives, took immediate action to ensure the resident was on the premises before instructing staff to regularly monitor the garden area. Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Residents’ needs are satisfactorily met by the number and skill mix of staff. EVIDENCE: There are sufficient staff working in the home to meet the National Minimum staffing requirements. However each day one member of care staff has kitchen duty, which takes their time away from caring for residents. On talking with staff and the manager of the home, it was determined that between 4-6 hours of care time each working day is taken up with kitchen duty, and a further one hour is taken up with laundry duty. The acting manager is providing staff with good training opportunities and supervision. She has good systems in place to monitor the effectiveness of staff, and their training needs. Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37,38 The management at the home is good, with many improvements to care practice being introduced by the new acting manager. EVIDENCE: The acting manager has spent time going through the care files of residents to ensure all their health and care needs are being met. She is closely supervising staff to ensure the home is being run in the best interests of the residents, and has put into place staff training where she feels it is necessary to support good health and social care. Although there have been many improvements since the last inspection, through discussion, the Manager demonstrated a determination to improve other aspects of the home that she had not yet had time to rectify. Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 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 Standard No 16 17 18 Score 3 x 3 4 3 4 x x 3 3 3 Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 19 none 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. 1. Standard 19 Regulation 13(4) Requirement Management must continue to ensure window restrictors are in operation, and that the side gate to the garden is secure. Management must provide an action plan demonstrating the training and supervision to be given to the member of staff identified as inaccurately recording adminstration of medication. Timescale for action immediate and ongoing. 20/08/05 2. 9 13(2) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 7 10 19 27 Good Practice Recommendations Encourage service users whenever capable, and/or their representative to sign their care plans. Involve residents and their family and friends (if acceptable to the resident) in planning for and dealing with arrangements for death. Consider making the garden furniture more comfortable to encourage residents use of the garden. Consider reviewing the deployment of staff to reduce the length of time care staff are involved in kitchen and laundry duty. C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 20 Brockshill Woodlands 5. 38 Refresh staffs understanding of vulnerable adult policies and procedures and the whistle blowing procedure. Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 21 Commission for Social Care Inspection The Pavillions 5 Smith Way, Grove Park Enderby LE19 1SX 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 Brockshill Woodlands C51 C01 S1814 Brockshill Woodlands V225957 200605 STAGE 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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