Inspection on 01/02/07 for Brockworth House Care Centre

This inspection was carried out on 1st February 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brockworth House Care Centre 21/11/05

Brockworth House Care Centre 30/06/05

Brockworth House Care Centre 21/12/04

Brockworth House Care Centre 01/07/04

Brockworth House Care Centre 08/01/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOMES FOR OLDER PEOPLE Brockworth House Care Centre Mill Lane (off Shurdington Road) Brockworth Glos GL3 4QG Lead Inspector Mr Adam Parker Key Unannounced Inspection 08:30 1st February 2007 & 5 February 2007 & th 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 Brockworth House Care Centre DS0000035042.V320055.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. Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brockworth House Care Centre Address Mill Lane (off Shurdington Road) Brockworth Glos GL3 4QG 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) 01452 864066 home.fxg@mha.org.uk Methodist Homes for the Aged Deborah Margaret Phillips Care Home 55 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (55), Mental disorder, excluding learning of places disability or dementia (1) Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The Registered Manager’s Award is to be completed. A post registration course in dementia is to be completed by April 2007. The one DE place to be for a named individual only. This category will be removed from the registration once this service user reaches 65 years or leaves the home. All Service Users admitted to the home in the category of Dementia (DE) are over 55 years of age. 21st November 2005 Date of last inspection Brief Description of the Service: Brockworth House is a purpose built two-storied nursing home, situated on the A46 road between Stroud and Cheltenham, approximately 6 miles from both Cheltenham Town and Gloucester City. There are local amenities available in the centre of Brockworth Village and a regular bus service to both Gloucester and Cheltenham. The home is set in large grounds which residents are able to access with the assistance of staff. There is an enclosed patio area for residents to access on their own if they are able. The home provides 53 single rooms and 1 double room, all with en-suite facilities. Some of the single rooms also have a connecting door between them to allow for a husband and wife to share. There is a large lounge/ dining room area on each floor, a smaller quiet lounge and several seating areas in the wide corridors, and assisted bathrooms and toilets on both the ground and first floor. The kitchen and laundry is situated on the ground floor. The home provides care for older people with dementia. Current fees are £530.00 to £653.00. Hairdressing and Chiropody are charged extra. The home makes information about the service, including CSCI reports available to service users and their representatives through a service user guide and statement of purpose available in the home. Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was carried out by one inspector over two days in February 2007. The registered manager of the home was present for the inspection visit which consisted of a tour of the premises and examination of service users’ care files. In addition staff recruitment and training was looked at as well as documents relating to the management and safe running of the home. A sample of service users were selected for inspection against a number of outcome areas as a ‘case tracking’ exercise. Comment cards were received from relatives of service users, staff in the home and one from a General Practitioner (GP). The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: Systems are in place for assessing service users’ needs and planning their care with the involvement of their relatives. Care plans are subject to review and the home is changing over to support plans with a person centred approach. Care is delivered in such a way as to uphold service users’ privacy and dignity. The home provides a range of suitable activities and maintains strong links with service users relatives and contact with the community. Service users are provided with a choice of meals and are enabled to make choices as to their preferences in relation to their abilities. There is an excellent approach to dealing with complaints and the home is open about bringing this to the attention of service users’ representatives. A high priority to training staff in recognising and preventing abuse to service users and good information is provided about this to both staff and service users’ representatives. The home was well maintained and clean providing service users with a safe and comfortable environment. It has been well staffed to meet service users’ needs and well managed to provide good outcomes for service users. The home ensures that staff are trained in safe working practices and regular safety checks are carried out on the environment. Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 6 Service users are protected from the risks of Legionella by an advanced water treatment system installed in the home. What has improved since the last inspection? 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. Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 7 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 Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 8 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedure ensures that all service users are admitted to the home on the basis of a full assessment of their needs, so that they can receive the care that they require. EVIDENCE: The assessment documentation for six service users recently admitted to the home was looked at. These had been completed following an assessment of the service user’s needs by the registered manager or deputy manager prior to admission to the home. In one case for example the assessment had been completed by the registered manager while the service user was still in hospital. Nursing assessments had been completed where appropriate as well as social assessments. In addition copies of discharge summaries from hospitals had been obtained as well as assessments and care plans carried out by the funding authority. In one case the home had obtained the assessment from the Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 9 funding authority relating to a service user who had been in another care home, further information relating to the service user’s needs was actively sought but not forthcoming from the previous home. The registered manager stated that information from funding authorities was sometimes delayed although the home were happy that their own assessment was thorough and would enable them to decide if they could meet the service user’s needs. Information recorded on assessment included service users religious beliefs and arrangements following death. Examples were given of potential service users who were not admitted to the home following an assessment and the home identified that they could not meet their needs. The home is in the process of changing over to a ‘personcentred’ approach to assessment and care planning and has started to use a ‘living skills’ admission assessment summary, the example seen contained detailed and individualised information. The home does not provide intermediate care and so Standard 6 does not apply. Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 & 9 Quality in this outcome area is good, although there are still some shortfalls in relation to Standard 9. This judgement has been made using available evidence including a visit to this service. There is a move towards a ‘person centred’ care planning system which provides staff with information to meet service users’ needs. The home works well to meet service users’ health needs through liaison with health care professionals. There are still some shortfalls in medication administration records and storage that may compromise the home’s ability to fully meet the medication needs of service users. Care is given in such a way as to promote the privacy and dignity of service users. EVIDENCE: Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 11 The home is undergoing a change in the format and style of care plans and moving to a ‘person centred’ approach with support plans some of which cover areas that have to be completed. Examples of care plans and support plans were looked at during the inspection. Some of the care plans had not been reviewed on a monthly basis and the registered manager attributed this to the change over to the new support plan format. Some care plans had been reviewed with input from the service user’s relative. Care plans and support plans were clearly derived from assessments with one care plan for social isolation linked to information in a social assessment and care plans for pressure area care and nutritional needs linked to the outcomes of clinical risk assessments. One service user was receiving input from mental health services following discharge from hospital and the home had received information about this including documentation under the Care Programme Approach. This should be reflected in the appropriate care plan to ensure that it is clear when input should be sought from mental health services. Out of 33 comment cards received from relatives of service users,32 indicated that they were satisfied with the overall care provided in the home. One comment card included the statement “I cannot fault the staff and care that my Mum receives at Brockworth House.” Risk assessments had been completed for falls and falling out of bed as well as clinical risk assessments. Pressure area risk assessments had been subject to a monthly review. Service users had also received a mental health assessment completed by the home which had resulted in appropriate care plans where required. One service user who had a wound that required regular dressings had a plan for this based on a wound dressing assessment with a skin inspection chart also completed. There was evidence of service users having input from health care professionals such as GPs, physiotherapists, mental health nurses as well as chiropodists. Service users had received influenza vaccines and this process had involved liaison with their relatives. Medication administration and storage arrangements were looked at and requirements issued following the previous inspection were checked. Medication administration records still had some shortfalls in recording such as where medication was not given the reason needs to be recorded or if it was administered then it must be signed for. All administration must be recorded for creams and ointments. Areas where administration recording had been missed were noted and the registered manager was informed. Hand written entries on medication administration sheets had been signed in some cases but not dated and with others there was no date or signature. These entries should be checked to ensure accuracy and prevent any possible administration errors. Medication is stored in two locations within the home. In the downstairs storage area temperatures had been monitored although these indicated that storage was above 25°C and so medication had not been stored at the correct Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 12 temperature. The registered manager was aware of this. It was reported that temperature checks in the upstairs storage had previously been carried out and found to be at the correct level. Storage temperatures of medication in the refrigerator were being monitored, these were generally within the correct range although some were below and monitoring should continue. Most liquid and topical medication had been dated on opening. Medication administration practice was subject to risk assessments for disguising medication and for the administration of creams and ointments. Each service user had a medication profile completed which included information on allergies, diagnosis, particular preferences or routines and special administrative instructions. This is good practice. A ‘homely remedies’ list was seen which had been signed by a GP. Medication audits take place every two months. The home is involved in a project about the ordering and use of dressings in the home in conjunction with the Primary Care Trust. The comment card response from a GP indicated that medication was appropriately managed in the home. Staff were observed treating service users with respect and up-holding their privacy. The home has no shared rooms although the facility exists for a couple to share rooms if required making use of interconnecting doors fitted in some rooms. The shower room on the ground floor includes a curtain across the door way to ensure privacy. One comment card received from a relative of a service user stated “ My Mother is treated with respect at all times.” Privacy and dignity is included in induction and dementia training for staff and this was confirmed in surveys received from staff working in the home. Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a comprehensive activities programme, maintaining links with the local community and places no unnecessary restrictions on visitors in order to provide service users with appropriate and flexibly provided ongoing social activity and individual stimulation. Service users’ dietary needs are well catered for taking into account choice and nutrition. EVIDENCE: The home has two activities coordinators who are not counted in the care staffing numbers and work at weekends and evenings. They offer a range of activities for service users both inside and outside of the home for example a cookery group, poetry reading, walks outside and physical exercises. The home keeps a record of service users’ interests in a personal profile which includes a life history. In addition a record is kept of activities that service users take part in as well as a record of visits from relatives and friends. Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 14 At Christmas, service users were able to take part in a range of activities including a Christmas fair and carol singing. Recently Burn’s Night had been celebrated with a bagpiper playing in the home. In addition a celebration of Chinese new year was planned which may be appropriate to a service user in the home from a Chinese ethnic background. Methodist Homes have recently provided financial input specifically for the provision of activities to service users. The home enables service users to maintain contact with family, friends and representatives. Visitors were welcomed into the home and were able to visit service users in communal areas or their individual rooms. Out of 33 comment cards received from relatives of service users, 32 indicated that they could visit their relative in private, one indicated that they could not. The home is pro-active in maintaining links with service users relatives by holding regular meetings, the minutes of which were seen, discussions took place and relatives were informed of developments in the home. The home also has a camera available for relatives to use to record family events and to take on outings with service users. This facility is to be extended to enable family photographs to be recorded on a DVD for service users to view. The home maintains links with the local community in particular a group from the local Methodist Church who have on going involvement with the home supporting activities. There are also links with the chaplain of a Baptist church in Cheltenham. Due to the abilities of service users in the home, none are able to control their own finances relying on relatives and representatives for this. Evidence was seen of service users bringing their own personal possessions into the home. The home had previously used a contractor to provide meals but this changed in July 2006 and meals are now provided by the home. The menu changes every week for four weeks. It includes a choice of two main courses with extra alternatives such as salads, jacket potatoes and omelettes always available. Supper involves a choice of a cooked meal or sandwiches with a desert. At lunchtime staff were seen to be attentive to service users’ needs with catering staff serving the meals and care staff offering assistance to those that needed it sitting at the meal tables with the service users. As well as the main dining area, service users also took meals at small individual tables in other lounges. A number of care staff have been trained in food hygiene. The home has catered for special diets such as vegetarians but was not doing so at the time of the inspection. The home helps service users to choose meals by showing them a small sample of each dish before the meal is served. This is good practice in relation to enabling choice in service users with dementia. Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has a clear complaints procedure and information about this is available to service users’ representatives should they wish to make a complaint. The home gives a high priority to protecting service users from abuse through information and staff training. EVIDENCE: The home’s complaints procedure is displayed in the entrance hall of the home, it details a response to a complaint within 15 days and links complaints to providing the best possible service. The procedure includes the address of the Commission for the referral of any complaints. The home had received four complaints in the past 12 months and was able to show the responses to these. The registered manager described how the home had learnt from complaints and changed its practice in relation to one complaint about contacting a service user’s relative following their death. Complaints referred to the home are investigated by the head office of Methodist Homes. Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 16 The home also demonstrated how comments from a survey of relatives of service users had been picked up and dealt with as a complaint which is good practice. The registered manager reported that complainants had been happy with responses received and in one case the deputy manager had been involved in on-going meetings with one complainant to ensure that issues were still being addressed to the person’s satisfaction. Out of 33 comment cards received from relatives of service users, 24 indicated that they were aware of the home’s complaints procedure and 9 were not. The home has robust procedures for responding to suspicion or evidence of abuse. Staff are given written guidance on reporting suspected or actual abuse and Methodist homes has set up a freephone number for reporting abuse and this is publicised to staff in a leaflet entitled “No Secrets Here”. In addition staff (including ancillary staff) receive training on abuse and complete a questionnaire following the training to check their understanding. At the time of the inspection there were a number of new staff who had not completed the training although this was scheduled for February 2007. A small group of staff were spoken to and they recounted what they had learned from the abuse training and how this would influence their care practice. The home also has the contact details for the local authority adult protection team. Brockworth House Care Centre DS0000035042.V320055.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): 19,24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have the benefit of living in a well maintained and generally clean, environment with personalised individual rooms although some work needs to be done to control odours in communal areas. EVIDENCE: A tour of the premises was conducted, this revealed that the home was well maintained and generally clean. A few minor maintenance issues were noted which the registered manager referred directly to the maintenance man for attention. It was noted that some toilet doors had pictorial signs attached to aid identification for service users. At the side of the home there is an enclosed garden accessible through the downstairs lounge. At the time of the inspection there were some uneven paving stones which presented a potential tripping hazard. The registered manager stated that work was planned to make this area safe before service users could enjoy it in the fine weather. Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 18 Individual service users rooms were looked at, many of these contained personal items including items of furniture. The condition of pillows, pillowcases and bed clothing was looked at in a number of rooms and these were found to be clean and of a good standard. Generally service users’ rooms are locked during the day to protect their contents. The home gives a high priority to hygiene, providing staff with suitable hand washing facilities including anti bacterial soap and hygienic hand rub and reminders about hand hygiene. Staff were noted making use of these facilities to washing their hand during the inspection. Service users rooms were fresh and odour free although on both days of the inspection it was noted that some corridors and communal areas did not have a pleasant odour and were rather stale. This was also mentioned in one comment card from a relative of a service user who stated “The home often smells unpleasant which does not give a good impression”. Following the inspection the inspector was contacted by a visitor to the home who made a similar observation. The laundry was clean and well organised with washable floor and wall surfaces. Brockworth House Care Centre DS0000035042.V320055.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well staffed to meet service users needs. The level of NVQ training should increase to ensure that service users are in safe hands. Shortfalls in obtaining required information for staff recruitment have potentially failed to support and protect service users. Induction and foundation training should ensure that staff are trained and competent to meet service users’ needs. EVIDENCE: Out of 33 comment cards received from service users relatives,18 thought that there were always sufficient staff on duty and 14 did not with 1 not providing a response to the question. The subject of staffing had been discussed at a relatives meeting in January 2007 where it was announced that with new appointments the home would be overstaffed. On the day of the inspection as well as the registered manager and the deputy there were two registered nurses on duty, a training coordinator, two senior care assistants and 7 care assistants working at different times throughout the Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 20 day. In addition to the nursing and care staff there were a chef and two kitchen assistants, two cleaners in the morning and one in the afternoon. There was also a laundry worker a maintenance worker and two activities coordinators. The night shift on the first day of the inspection consisted of three registered nurses, a senior care assistant and a care assistant. The home’s training matrix shows that out of 25 care staff and 2 activities coordinators there are 13 trained to an NVQ level 2 or above, just below 50 . One member of staff is currently undertaking NVQ and another 4 are to be enrolled on a course. Seven recent staff recruitment files were looked at with three of these there were shortfalls with all required documentation and information not being obtained prior to employment commencing. Two written references had not been obtained and employment histories were insufficient to accurately determine gaps in employment. In addition reasons for leaving previous employment with vulnerable people had not been verified. The registered manager confirmed that ‘PoVA first’ checks were being carried out before staff started work (prior to the full criminal records check being received) but there was no documentary evidence on file and it is recommended that these should be kept for future reference. Staff starting work prior to the receipt of a criminal records check are supervised until this arrives, working with an identified member of staff where possible. Staff are provided with induction and foundation training in line with national specifications and Methodist Homes policy manuals. The progress of staff induction in the home is checked by the head office. Eight staff surveys were received relating to the inspection, six staff confirmed that they had induction training, one indicated that this had been partial and one stated that they had not received induction training. The registered manager confirmed that some overseas staff were having English lessons. Staff have also had training in dementia awareness with more planned. Brockworth House Care Centre DS0000035042.V320055.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): 31,33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed with a variety of quality assurance audits in operation to ensure that the home is run in the interests of service users. The home has arrangements for ensuring that service users’ financial interests are safeguarded. Safe working practices ensure service users’ safety. EVIDENCE: The registered manager is a registered nurse and has completed the Registered Managers Award which is currently awaiting assessment and has also undertaken a course in dementia care. She has past management Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 22 experience in a care home and has recently completed relevant training in managing and training staff through the Methodist Homes Management development Programme. She works full time and is supernumerary to the care staffing. The home uses a variety of quality audits, these include audits of accidents, care plans, pressure area care, activities and a team quality audit. In addition the home has a quality audit day in the past when it seeks the views of stakeholders in the home. Due to the nature of the service users in the home, a questionnaire is prepared and given to relatives to complete instead of service users a collection of the responses to this was seen and the registered manager was planning to prepare an action plan. The home produces and carries out action plans based on its audits. The home has arrangements for the safekeeping of service users money using a bank account which is specific for the purpose and separate from any account used for the running of the home. The home has a record of the amount of money held on behalf of each service user in the account and does not generally keep service users’ cash although facilities exist if needed. The home has ensured the servicing and maintenance of electrical and heating systems and appliances as well as hoists and the lift. Regular checks are made on hot water temperatures and these are recorded along with a number of other safety checks such as window restrictors. The home has an advanced ionization system of water treatment for managing the risk of Legionella and the maintenance man carries out actions in relation to this. The home keeps a record of accidents and incidents and monitors these with an audit. Hazardous substances are stored safely and securely in line with relevant regulations with no decanting of substances into unmarked containers which is wholly appropriate to protect the service user group in the home. The home has a comprehensive set of risk assessments for the environment including security of the premises. Staff have received health and safety training as well as training in infection control, moving and handling, control of hazardous substances, food hygiene and fire training. Fire drills have been held in the home with the most recent being January 2007. This was observed and staff actions recorded. Regular checks are also made on fire alarms and fire exits. Brockworth House Care Centre DS0000035042.V320055.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 X X X X 3 X 2 STAFFING Standard No Score 27 4 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 4 Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement The registered person must ensure that any omissions in the administration of medication are qualified with an explanation of the omission code used. This requirement has been repeated from the previous inspection. The registered person must ensure that the administration of all topical applications is recorded. This requirement has been repeated from the previous inspection. The registered person must ensure that all medication stored in the home is kept at the correct temperature. The registered person must ensure that in order to protect service users from possible medication errors all hand written directions should be signed and dated by the staff member making the entry. The registered person must investigate and eliminate unpleasant odours in communal areas and corridors. DS0000035042.V320055.R01.S.doc Timescale for action 31/05/07 2. OP9 13 (2) 31/05/07 4. OP9 13 (2) 31/05/07 5. OP9 13 (2) 31/05/07 6. OP26 16 (2) (k) 31/05/07 Brockworth House Care Centre Version 5.2 Page 25 7. OP29 19 (1) (b) Schedule 2 The registered person must ensure that all the information and documents specified in Schedule 2 of the Care Homes Regulations are obtained before a person is employed to work at the home. 31/05/07 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 OP7 Good Practice Recommendations Where the home has copies of the care programme approach arrangements for service users receiving input from mental health services then these should be reflected in the appropriate care plan. All topical and liquid medication should be dated on opening. Hand written entries on medication administration charts should be checked and signed by a second member of staff. The level of care staff trained to NVQ level 2 should be increased. Application forms should allow for the inclusion of more detailed information regarding dates of previous employment. 2. 3. 4. 5. OP9 OP9 OP28 OP29 Brockworth House Care Centre DS0000035042.V320055.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Brockworth House Care Centre DS0000035042.V320055.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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