Inspection on 21/11/05 for Brockworth House Care Centre

This inspection was carried out on 21st November 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

Brockworth House Care Centre 01/02/07

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 Unannounced Inspection 21st November 2005 09:45 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.V269499.R01.S.doc Version 5.0 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.V269499.R01.S.doc Version 5.0 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 Methodist Homes for the Aged Deborah Margaret Phillips Care Home 55 Category(ies) of Dementia (1), 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.V269499.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. 30/06/05 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. Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on one day in November 2005 by the lead inspector. The registered manager was present throughout the inspection and was able to give assistance as required. The inspector also spoke to one of the administrators and two of the registered nurses. Care files were examined as well as medication administration and storage arrangements. In addition the complaints procedure and quality assurance systems were looked at. The staffing levels, staff and management training were also examined as well as the arrangements for dealing with service users money. What the service does well: What has improved since the last inspection? What they could do better: Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 6 Improve medication administration records and arrangements for storing medication. 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. Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 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.V269499.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards assessed in this section EVIDENCE: Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 7,9 & 11 The home has a clear and consistent care planning system in place to adequately provide staff with information to meet service users needs. There are some shortfalls in medication administration records and storage that may compromise the home’s ability to fully meet the medication needs of service users. Arrangements are in place for the needs of service users who are dying in order to provide respect care and pain relief. EVIDENCE: Following a requirement at the last inspection the home has now ensured that service users have care plans for all their assessed needs or if not there is a statement to explain this. The medication administration and storage arrangements were looked at. Every service user had a risk assessment for medication although these were not up to date. Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 10 Medication administration records had some shortfalls in recording such as where medication was not given the reason needs to be recorded and all administration must be recorded for creams and ointments. Hand written directions on medication administration sheets had not been signed in all cases. In addition storage temperatures in the medication refrigerator were above the correct level. A regular record needs to be kept of the storage of medication in all areas to check that these are within manufacturer’s limits. The home should also check the wall fittings used for the controlled drug cupboard and information about this has been sent to them. It would be good practice for care plans to include actions for sedative medication given on an ‘as required basis’. On the positive side the home did have a list of homely remedies approved by the GP and service users allergies were recorded on administration sheets. Staff had received additional training in the covert administration of medication. The home has arrangements in place to deal with the care of service users who are dying. On admission the service user’s wishes concerning death and dying are discussed with relatives and recorded. The home allows relatives to stay with a service user during their final days and is able to make some space available for their needs. The records of a service user who died in the home were examined and revealed that appropriate care had been given as well as appropriate pain relief through liaison with the GP.Staff have also received training on death and dying. Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 11 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 the following standard(s): No standards assessed in this section. EVIDENCE: Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 16 The home has a clear and accessible complaints procedure for addressing complaints made on behalf of service users. 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. The procedure includes the address of the Commission for the referral of any complaints. The manager reported that she operates an ‘open door’ policy for any concerns from service users representatives. In addition a relatives meeting is held on a regular basis. The home had not received a complaint for 6 months according to its complaints log. Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 13 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 the following standard(s): No standards assessed in this section EVIDENCE: Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 & 30 After some past instability in staffing there is now a consistent staff team deployed in sufficient numbers to more than adequately meet the needs of service users. The home is working towards achieving 50 of care staff trained to NVQ level 2 to ensure that service users are in safe hands. Induction and foundation training is provided to ensure that staff are competent to do their jobs. EVIDENCE: The home bases staffing levels on the changing needs of residents and provides additional staff in response to other events in the home such as building work. The home deploys additional staff at mealtimes and the staff team has the support of contract caterers. The home has an activities coordinator working a ‘late’ shift enabling social needs to be met in the evenings. At night the home has 2 registered nurses and 3 care assistants to cover the home. Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 15 The home had around 30 of care staff qualified to NVQ level 2. A further 5 members of care staff are working towards the qualification with a further 5 ready to commence. This standard will be looked at again at the next inspection when the national deadline to meet the standard will have passed. New staff in the home receive induction and foundation training to recognised standards. Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33 & 35 The home is satisfactorily managed with the manager working towards achieving appropriate qualifications. The use of a variety of quality audits ensures that the home is run in the best interests of service users. The home has adequate arrangements to safeguard the financial interests of service users. EVIDENCE: The registered manager is working towards completing the Registered Managers Award and has plans to undertake an appropriate course in dementia care. She has past management experience in a care home and has recently completed relevant training in such subjects as dealing with violence and aggression, death and dying and documentation. Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 17 The home has a deputy manager and operates an ‘on call’ system for staff to contact management if the need should arise at any time. The home uses a variety of quality audits, these include an audit from Methodist Homes from the aged, an internal audit, and audits of accidents and care plans. In addition the home has a quality audit day 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. The home produces and carries out action plans based on its audits. The home has arrangements for the safekeeping of service users money and valuables although the facilities were not being used at the time of the inspection. In addition there is a separate bank account for service users money that is separate from any account used for the running of the home. Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A X X X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 1 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X STAFFING Standard No Score 27 4 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 4 X 3 X X X Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 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. The registered person must ensure that the administration of all topical applications is recorded. The registered person must ensure that medication stored in a refrigerator is kept within the correct temperature ranges. The registered person must ensure that a record is made of storage temperatures in medication cupboards and remedial action is taken if necessary to ensure these are within correct limits. The registered person must ensure that the correct fixings are used for securing the controlled drugs cupboard to the wall Timescale for action 31/01/06 2 OP9 13 (2) 31/01/06 3 OP9 13 (2) 31/01/06 4 OP9 13 (2) 31/03/06 5 OP9 13 (2) 31/01/06 Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 20 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 Refer to Standard OP9 OP9 OP9 Good Practice Recommendations Medication risk assessments should be kept under review. All hand written directions should be signed by the person making the entry. Care plans should include actions for the administration of hypnotic or anxiolityic medication prescribed on an ‘as required’ basis. Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Brockworth House Care Centre DS0000035042.V269499.R01.S.doc Version 5.0 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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