Inspection on 22/11/07 for Brockshill Woodlands

This inspection was carried out on 22nd November 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

Brockshill Woodlands 04/03/10

Brockshill Woodlands 01/03/10

Brockshill Woodlands 29/12/09

Brockshill Woodlands 19/08/08

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

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 Linda Clarke Unannounced Inspection 22nd November 2007 09:15 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.V354232.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.V354232.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 Mrs Jacqueline Payne 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.V354232.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. 3rd January 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 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 Inspections, Inspection Reports, are available by Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 5 request at Brockshills Woodlands. The fees at Brockshill Woodlands range from £327.00 - £470 per week. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, which included reviewing the previous Inspection Report, viewing the Annual Quality Assurance Assessment (AQAA), which is a self-audit tool completed, by the Registered Manager. We, the Commission for Social Care Inspection (CSCI) sent surveys to service users, service user relatives, care staff, health care professionals and General Practitioners, the CSCI received 43 of service user and relative surveys, 64 of staff, and 40 of health care professionals and General Practitioners. The unannounced site visit commenced on the 22nd November 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the service users. The method of inspection was ‘case tracking’. This involved identifying service users with varying levels of care needs and looking at how these are being met by the staff at Brockshill Woodlands. Four service users were selected and discussions were held with two of them, discussions were held with other service users and service user visitors, interviews were conducted with three members of care staff, and the Registered Manager and Manager, additionally service user and staff interaction was observed. The method of case tracking included the review of service users’ individual care records, and the reviewing of various staff records. What the service does well: Brockshill Woodlands supplies information for prospective service users, which enables individuals and their relatives to have a good understanding of the services offered by the home, before visiting to have a look around. A detailed assessment of a prospective service users needs are undertaken by a senior member of staff, often in conjunction with health and social care professionals. Service users can be confident that their health and care needs will be met by an enthusiastic and experienced staff team, who have a clear understanding of the needs of service users, especially with regards to the support and care of those with Dementia. Brockshill Woodlands has an inclusive atmosphere with regards to service users relatives, which ensures relatives are kept informed as to the changing care needs of service users, relatives are encouraged to visit and are made to feel welcome, and are encouraged to join in celebrations and events. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 7 Surveys sent out to service users relatives by the CSCI, to the question what does the service do well, the following comments were recorded: • • • • • The staff seem very caring and professional. There is no staff ‘turnover’ so that my mum receives care from staff she knows. Attention to individuals, including individual entertainment i.e. puzzles, bingo and days out. Carers care about the people they are responsible for. They provide an excellent service to my mother Excellent care of my mother at all times. The family are always made welcome when visiting. Good communication with manager and staff. Make the residents feel secure and loved. Surveys sent out to staff by the CSCI, to the question what does the service do well, the following comments were recorded: • • • • • • • Meet the needs of service users. Care for service users, meeting all their needs. The staff work as a good team, service users are treated with respect in a good environment. Treat all service users as an individual and respect their diverse needs. I feel we do really well in supporting all our service users with their specific care needs. We have a lovely friendly warm atmosphere, very pleasant, very clean and a fantastic relationship with all families. The service provides service users with the care and respect they need in a time in their life when they become vulnerable and dependent. The service looks after the service users very well; the standard of care is the best. All staff work as a team. The service provides a quality of life to the service users, in a warm homely atmosphere. Service users are treated as individuals, with consideration to equality, diversity and dignity. Surveys sent out to health care professionals by the CSCI, to the question what does the service do well, the following comments were recorded: • • • Liaises very well with the District Nurse Team, provides individual care to patients with Dementia. The times I visit the home, they carry out all procedures requested of them very well. When I visit the home I find everything is done to a very high standard What has improved since the last inspection? The management of medication including medication records has improved; no shortfalls were noted as part of this Key Inspection. Recruitment practices are robust, with all pre-employment checks being carried out before a member of staff commences their employment. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 8 What they could do better: Care plans could be improved, if written from the prospective of the service user, and include detailed information on preferred daily routines, which is of particular benefit to those service users with Dementia. Positive practices of staff supporting service users when distressed was observed, however often the triggers and responses required by staff were not in all instances documented. The dignity and independence of service users during mealtimes could be improved, by offering service users the chance to serve themselves from serving dishes, and the reviewing of the use of plastic tumblers for drinks. Surveys sent out to service users relatives by the CSCI, to the question how do you think the care home can improve, the following comments were recorded: • Encourage more mental stimulation for residents. Surveys sent out to staff by the CSCI, to the question how do you think the care home can improve, the following comments were recorded: • • • • More staff so we can spend time with individuals on a one to one basis. Extra staff so we could have more one to one time. Cleanliness of certain areas within the home. Have more staff to give more time to individuals Surveys sent out to health care professionals by the CSCI, to the question how do you think the care home can improve, no comments were recorded. 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.V354232.R01.S.doc Version 5.2 Page 9 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.V354232.R01.S.doc Version 5.2 Page 10 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 and 3. Standard 6 is not applicable, as the service does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives are supported to make informed choices through good information and a robust assessment process, which ensures individual care needs, can be met. EVIDENCE: Prospective service users and their relatives are provided with information as to the services provided by Brockshill Woodlands, documentation includes the Statement of Purpose and Service User Guide, which detail the aims, objectives and philosophy of care of the home, the terms and conditions of occupancy, information about staff including their experience, training and qualifications. Supportive documentation is also available, and includes information on how to raise concerns, accommodation, and catering and social opportunities. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 11 Information supplied in the AQAA (self assessment tool) advised that the Statement of Purpose and Service User Guide are available in different languages and formats upon request. Additionally Prime Life Ltd., to which Brockshill Woodlands is part of, supplied a copy of policies and procedures, which outline how the admission of service users including their assessment is managed. Relatives of service users visiting and service users spoken with, confirmed they had received a brochure which outlines the services offered by Brockshill Woodlands, and relatives of service users confirmed they had visited the home, prior to their relative moving in. The records of four service users were viewed, records contained a contract outlining the terms and conditions of occupancy, relatives visiting confirmed they had received a copy of the contract. Observations of staff and service user interaction evidence that staff have a clear understanding of the needs of service users, staff were observed offering reassurance and support to service users who became anxious or distressed due to their Dementia. Staff interviewed were aware of distraction techniques, which divert service users attention to promote their well-being by promoting conversations to a topic, which is positive and will be pleasant to the service user. Brockshill Woodlands has two cats residing at the home, the cats were seen as a positive influence on service users, service users enjoyed interacting with them, and for service users who were distressed or anxious they had a calming affect. The CSCI sent out surveys to service users and their relatives as part of the Key Inspection process, comment cards confirmed that service users and their relatives were provided with sufficient information about the home before moving in, and that all received a contract outlining their terms and conditions of occupancy. Surveys also reflected that the relatives of service users believe that the home meets the needs of their relative, and that they are kept up to date about their relative and events within the home. The four service user records included an assessment of need, which were undertaken prior to the individual moving in, which ensures that the needs of the person can be met. A representative of Social Services and in some case health care professionals where the individual is already in receipt of some care and support carries out assessments in some instances. In addition assessment are carried out by a senior representative of Brockshill Woodlands. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 12 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. Service users are well cared for having their tailored health and daily care needs met through personalised care. EVIDENCE: The care plans of four service users living at Brockshill Woodlands were looked at, the care plans were individual to the needs of the service user, and recorded specific areas of care and support needed. The care plan of the service user in receipt of personal care support was viewed; the care plan focused on all aspects of the individuals’ life and included physical health and well-being, mobility, mental health and well-being. The care plan details the services to be provided, supported with the aim of the care package and its goal. The care plan had been regularly reviewed, and was supported by a daily record of information written by the staff responsible Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 13 for the delivery of personal care, which detailed any views expressed by the service user or observations which impact on the care of the individual. Care plans could further be improved through a person centred approach and information as to service users preferred daily routines; this is particularly relevant where service users due to their health are unable to express their views. Discussions with staff and observations of staff interaction with service users evidenced that staff have a clear understanding of needs of service users, and are aware of how to support and offer reassurance to service users whose Dementia causes them anxiety and stress, this information is not always documented and may be lost should staff leave. Three visitors were spoken with during the site visit, all expressed satisfaction with the care their relatives received, all said that they are kept informed should the health of their relative deteriorate, and were confident in the abilities of the care staff, who relatives said were kind and caring. Staff spoken with confirmed that they are responsible for reviewing; in conjunction with a senior member of staff the care plans of service users to whom they are keyworker for. All service users are allocated a keyworker who oversee specific aspects of their care, including the reviewing of their care plan, overseeing the cleanliness of their room and ensuring personal items are purchased where appropriate. Daily records and care plans reflected service users access health care professionals when required, which include Chiropodists, General Practitioners and District Nurses. The Manager of the home on the day of the site visit spoke with and organised appointments with health care professionals. The CSCI sent out surveys to service users and their relatives as part of the Key Inspection process, comment cards confirmed that service users and their relatives are happy with the care they receive, and state that staff listen and act upon what they say, and that they receive the medical support they need. Surveys completed by service users and relatives contained additional comments: • • The care and understanding of my mother is excellent. Always caring and very helpful. Additionally the CSCI sent out surveys to health care professionals (District Nurses) and General Practitioners. Information collated from the surveys confirms that the care service seeks advice and acts upon it to manage and improve the health care of service users, and that any guidance given is documented. Service users privacy and dignity is respected, and expressed general satisfaction with the overall care provided to service users in the home. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 14 The CSCI also sent out surveys to staff of Brockshill Woodlands, which confirm that staff are involved in the reviewing of care plans. One survey contained an additional comment: • All staff are involved and are able to add any input towards the needs of individuals. All staff informed of any changes to individual care needs. Medication and medication records of three of the four service users were viewed as part of the case tracking process, all were found to be in good order. The supplying Pharmacist undertakes regular audits of and inspections of medication in the home. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 15 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. Service users make choices about daily living; with choices offered as to activities and meals, service user independence and dignity could be further improved with regards to mealtimes. EVIDENCE: During the morning of the site visit the Registered Manager supported by staff organised exercises to music, a number of service users participated, and appeared to enjoy themselves. Throughout the day music played in the background, and was reflective of the age and culture of service users. Daily records of the four service users case tracked were viewed, which detailed activities they had participated in, which included bus trips to a range of destinations which included Bradgate Park, Foxton Locks, Abbey Park and Rutland Water. Activities within the home included bingo, exercise to music, sing a longs and quizzes. Service users spoken with said they enjoyed the activities. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 16 Visitors visited throughout the day, all visitors said they were welcomed into the home, which was always warm and homely, visitors were greeted and offered a drink. Visitors and service user relatives are very much included in all aspects of service user care, and are welcomed to participate in significant events including birthdays and Christmas, which are organised by staff of the home. Two examples of this were observed on the day of the site visit one being the organisation of a birthday party including the making of a cake, to which service user relatives and friends were invited, and the other being an invitation for a relative to join in the Christmas meal, on Christmas Day. The CSCI sent out surveys to service users asking their views as to activities provided by the home, all indicated that they take part in the activities arranged, one service user stated they would like additional bus trips, the Registered Manager said that the practice of bus trips had been reviewed, and instead of two days per month, their were now four half days per month, which she felt was more appropriate to the needs of service users. Service users were asked as to whether they enjoyed the meals provided by the home, all spoke positively. On the day of the site visit, choices were available and the menu for the day is displayed on the notice board in the central lounge. There are areas for improvement with regards to mealtimes, for example service users could be encouraged to more self sufficient and independent through the use of serving dishes placed on the individual dining tables. It was also noted that service users had colourful plastic tumblers for their drinks, which does not promote the dignity of the service users. The CSCI sent out surveys to service users responses indicated general satisfaction with the meals. Refreshments were served throughout the day, and included snacks such as biscuits and sweets. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 17 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. Service users are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Brockshill Woodlands has a Procedure for handling Concerns, Comment & Complaints; this is provided to all service users and their relatives upon their moving into the home, additionally a copy of the Procedure is displayed in the entrance foyer. Information supplied by the Registered Manager in the AQAA states that the home has not received any concerns, and in addition the CSCI has not received any concerns or complaints about the service. Surveys completed by General Practitioners stated that no concerns about Brockshill Woodlands have been expressed to them. The CSCI sent out surveys to service users and their relatives, service users surveys reflected that a majority of service users know how to make a complaint and knew who to speak with if they were unhappy. Relative surveys reflected that a majority knew now to raise concerns, and all indicated where concerns had been raised they had been responded to appropriately. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 18 In addition the surveys sent to staff by the CSCI confirmed that staff know how to respond should concerns be directly raised with them. 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. Three members of staff were interviewed and were able to outline their roles and responsibilities. Discussions with staff and information viewed confirmed that staff receive training on how issues of concern regarding potential abuse are reported. Brockshill Woodlands in some instances is responsible for some aspect of service users financial management, which is in managed and audited by Prime Life Limited Head Office. Records of individual expenditure are kept on site, these were not viewed as part of the site visit, as the service users who were case tracked had their finances managed either by themselves of by their relatives, as documented within their care plan. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 19 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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with a warm, safe, clean, comfortable and wellmaintained environment suitable for their needs. 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. The home has an ongoing programme of refurbishment, which has recently included new carpets to the stairwell and lounge areas. Following recent legislation with regards to smoking, the home now provides a small separate lounge for service users and their visitors who wish to smoke. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 20 On the day of the site visit the home was clean and tidy, visitors said that one of the most attractive features of the home was its homeliness, and that their were several lounges, which service users could choose to sit in. The CSCI sent out surveys to service users and their relatives who indicated that they believe the home to be fresh and clean. Information completed by the Registered Manager in the AQAA reflects that the home has an ongoing commitment to refurbishment, and that service users are encouraged to personalise their bedrooms, including bringing in with them personal items. The home provides single and shared bedrooms. Brockshill Woodlands has Policies and Procedures which outline staff responsibility in ensuring that service users are protected from communicable diseases and infections, on the day of the site visit staff were observed wearing disposal gloves and aprons as required. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 21 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. Service users are protected by a robust recruitment process, and receive the appropriate support they require by staff that are experienced and trained, having their needs timely and safely met. EVIDENCE: On the day of the site visit, their were sufficient staff to meet the needs of service users, in the absence of the Registered Manager the overall responsibility for overseeing of the home falls on the Senior Care Worker. The CSCI sent out surveys to service users and their relatives, all indicated that there were staff available when they needed them. In staff surveys sent out by the CSCI staff in a majority of instances felt their were sufficient staff to meet the needs of service users, however some felt that additional staffing would enable staff to spend more one to one time with service users. Information supplied by the Registered Manager in the AQAA states that 35 of staff have attained a National Vocational Qualification in Care, this being short of the 50 specified within the National Minimum Standards for achievement by 2005. Staff spoken with said that they had enjoyed working Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 22 towards their NVQ and that gaining the award had been of benefit to them and the care service users receive. The staff records of two members of staff who were keyworkers to the service users case tracked were viewed, all were found to contain information required for the employment of staff, which included a completed application form, two references and a Criminal Record Bureau (CRB) disclosure. Staff surveys sent out by the CSCI also evidence that staff had undergone a robust recruitment process. The recruitment process is overseen by the Prime Life Human Resource Department, and is supported by Policies and Procedures, and includes random audits of staff files held by the home by the relevant Department. Staff spoken with said they had received training relevant to the health, safety and welfare of service users, which included First Aid, Fire Awareness, Moving and Handling and Hoist Awareness. In addition staff said they had received training reflective of the needs of service users which included a course in Dementia Awareness, which is a modular course run by a local College, lasting over several weeks. Surveys sent out by the CSCI to staff reflected that staff are happy with the training they receive. Additional comments were made:• • • I get all the relevant training, which also helps me, progress within my role. Any areas I am unconfident or unsure about the training is provided. Having never done care before I was very nervous. The induction gave me a better understanding and more confidence. Surveys sent out to health care professionals (District Nurses) by the CSCI recorded that the staff have the right skills and experience to support service users social and health care needs. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 23 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. Service users benefit from a well managed home with good leadership, ensuring that service users health, safety and welfare are promoted. EVIDENCE: The Registered Manager, Jackie Payne is shortly to leave her position at Brockshill Woodlands, a new Manager has been appointed, whom the existing Registered Manager is currently inducting. The new Manager has a National Vocational Qualification (NVQ) at level 4 in Care, and has recently registered with a local college to undertake the Registered Managers Award. The new Manager, will in the near future be submitting her application to the CSCI for consideration to become the Registered Manager. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 24 Prime Life Limited last undertook a Quality Assurance review of the home in August 2006, the Registered Manager was unclear as to when the next Quality Assurance review would be undertaken. The most recent Quality Assurance review, involved service users, their relatives and staff, areas of strength and weakness were identified, which included actions that would need to be undertaken to improve the service. The Registered Managers’ line manager visits monthly, leaving a record of their visit, including any actions that Prime Life as a Company or the Registered Manager has to fulfil. Service user and staff meetings also take place, with minutes being available. Surveys completed by service users, relatives, staff, health care professionals and General Practitioners reflect that information is managed well, which promotes consistency of care. Finances are in some instances managed by the Head Office of Prime Life Limited, with records held by the home being subject to audit. Policies and Procedures are in place for the Management of Clients Money and Financial Affairs. Records of service users finances were not viewed on this occasion, as service users who were picked as part of the case tracking process, had their finances managed by themselves or relatives, as detailed within their care plan. Staff were asked as to whether they receive regular supervisions, staff said that supervisions were frequent and were either observational, whereby the Registered Manager worked alongside them reviewing their work practices. Supervisions also were on a one to one basis, which were a discussion as to the staffs training needs, and review of care practices. Surveys sent out to staff by the CSCI reflected that they feel information is managed well in the home, and that they feel supported by their Manager. Additional comments were recorded within surveys: • • • Manager regularly gives support and feedback to me therefore I am aware of how well I am doing in my role. Really good communication between staff and Manager. We have improved staffing levels in the mornings, however the home caters mostly for service users with Dementia, individuals need extra input and support which is hard working with minimum staffing. Information supplied by the Registered Manager in the AQAA details the regular maintenance of health and safety systems within the home, including fire systems and equipment, environmental health visits, central heating systems and emergency call systems. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 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 3 3 X X N/A 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 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 Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 26 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. 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. 1 Refer to Standard OP15 Good Practice Recommendations It is recommended that service users independence and dignity be promoted at mealtimes, by the revision of current practices, to include consideration to service users serving themselves from serving dishes placed on dining tables, and by a review as to why service users use colourful plastic tumblers for cold drinks. Brockshill Woodlands DS0000001814.V354232.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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.V354232.R01.S.doc Version 5.2 Page 28 - 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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