Inspection on 27/03/07 for Brompton House Nursing & Retirement Home

This inspection was carried out on 27th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Brompton House Nursing &... 23/06/08

Brompton House Nursing &... 05/01/06

Brompton House Nursing &... 12/07/05

Brompton House Nursing &... 19/01/05

Brompton House Nursing &... 12/05/04

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

CARE HOMES FOR OLDER PEOPLE Brompton House Nursing & Retirement Home Station Road Broadway Worcestershire WR12 7DE Lead Inspector Yvonne South Key Unannounced Inspection 09:30 27th March 2007 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 Brompton House Nursing & Retirement Home DS0000004099.V328331.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. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brompton House Nursing & Retirement Home Address Station Road Broadway Worcestershire WR12 7DE 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) 01386 853473 01386 853808 franciam@bupa.com www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited Miss Amanda Jane Francis Care Home 45 Category(ies) of Dementia - over 65 years of age (43), Old age, registration, with number not falling within any other category (45), of places Physical disability over 65 years of age (45) Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No conditions in addition to those listed earlier. Date of last inspection 05.01.06 Brief Description of the Service: Brompton House is a care home providing accommodation, personal care and nursing care for up to 45 older people of either sex. The home is owned by BUPA Health Care, and the registered manager is Miss Amanda Francis. The home is located on the outskirts of the village of Broadway and within reasonable walking distance of the high street, which provides a range of shopping facilities. It is a large converted house, and was first registered under the Registered Homes Act 1984. Accommodation for residents is provided on the ground and first floor, and all the bedrooms are single occupancy, with en-suite facilities. Access to the first floor is gained through either a staircase or through the use of a central passenger lift (for residents who are mobility impaired). Handrails and grab rails are fitted where appropriate. Lifting aids are available in communal bathrooms. There is parking at the front of the house, a courtyard garden to which a number of ground floor rooms have access and a good-sized garden at the rear of the house. It was confirmed on 27.03.07 that the current scale of current charges ranged from £237.18 (plus top up) to £825.per week. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that incorporated information received by the Commission for Social Care Inspection (CSCI) since 05/01/06 and the information obtained during fieldwork on 27.03.07. The fieldwork took place over nine hours during which the inspector spoke to three residents and six staff. Documents were assessed and a partial tour of the premises was also undertaken. Assistance was principally given by Mrs Amanda Cockle, the Education Coordinator, as Amanda Francis the registered manager was on leave. Prior to the fieldwork the home was asked by the CSCI to complete and return a pre-inspection questionnaire, and to distribute questionnaires to the residents, relatives and health care professionals seeking their opinions of the service. To date 9 responses have been received from residents, 13 from relatives and 1 from a health care professional. The focus of this inspection was on the key National Minimum Standards and requirements and recommendations that arose out of the previous inspection. It was observed that the home was registered to accommodate and provide care for a maximum of 45 people. This was reflected in the registration certificate. However the Education Co-ordinator said that to her knowledge only 39 places were now available. It was stated in the pre-inspection questionnaire that was completed by the registered manager, that there were only 39 single rooms provided. This anomaly may have arisen when double rooms were changed to single occupancy and an unsuitable room was taken out of use. The inspector advised that it would be in the home’s financial interest to correct the registration by making an application in writing to the Central Registration Team. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Minor improvements need to be made to care records, medication management and infection control so that residents receive the care they need in safety. Information needs to be gathered concerning residents’ end of life wishes so that staff are able to respond as needed. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 7 Staff should receive regular individual support so that they are able to improve and develop their skills and roles for the benefit of the residents and themselves. Improvements need to be made to storage facilities and security so that safety is addressed and facilities are available for their designed purpose. Staffing levels need to be reviewed so that residents receive the attention they need in a timely manner. 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. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (An intermediate service is not provided therefore Standard 6 was not assessed.) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive the information they need to help them make a decision regarding their future accommodation and care in the home. The home does not admit people whose needs they cannot meet. EVIDENCE: In the questionnaire responses received from residents and relatives it was confirmed that they considered they had received sufficient information to enable them to make a decision regarding the home and their future care. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 10 A Statement of Purpose was available in the home and every resident received a welcome pack and Service Users’ Guide when they moved in. The questionnaires and documents assessed during fieldwork demonstrated that someone from the home had visited the prospective residents and assessed their needs prior to offering them places. This ensured the staff in the home would be able to meet the needs of each person. A comment in one questionnaire completed by a resident stated: ‘My wife and I were not able to visit the home in advance but friends who use it spoke well of it and the home manager visited us at home to discuss fully my needs and the facilities the home offers. I was assured the home had staff experienced for my particular needs.’ Three sets of care records were assessed. One pre- admission form concentrated on priority needs as the admission was an emergency. The second person came from a distance and the home received information from the discharging hospital. The pre-admission assessment form was not fully completed but provided enough information to support a decision. The form was basically a tick box format with minimal space for individual details and information. It did not ask for information relating to all the topics listed in Standard 3.3 of the National Minimum standards. Therefore some information was not being sought. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical and health care needs of residents are regularly reassessed so that the care plans are kept up to date and provide the information and guidance to enable staff to meet each person’s needs. EVIDENCE: Questionnaire responses from residents and relatives were most complimentary regarding the standard of care provided. The inspector spoke to three residents and although only one person was able to undertake a full conversation they all indicated that they were pleased with their care and the staff were ’lovely’. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 12 The care records indicated that needs had been assessed and care plans had been generated and regularly reviewed. All care plans were good. Two of the three care plans were very good in the detail and information they provided to inform and guide staff. There were some weaknesses. For example there was no care plan to address an identified risk of falls. Some documents were not dated and signed. There was no evidence that the residents and/or their relatives had been involved in discussions regarding two of the three sets of care plans. There was no information regarding residents’ end of life care wishes. Daily records indicated that care was being delivered in accordance with the plans. Health care professionals visited the residents in the home and the residents were supported to keep appointments in the community. The questionnaire responses from residents and their relatives indicated that they were pleased with the health care and support provided. The GP who completed a questionnaire gave positive answers to all questions. A short assessment was made of medication management. It was observed that long-term residents used the Nomad modular system of medication management. Storage was acceptable and records had been well maintained. However it was observed that stocks delivered outside of the regular supply were not always recorded when checked in. When stock is given to a resident who self-medicates this should be recorded to maintain an audit trail. Although in the past it was considered to be acceptable, the British Pharmaceutical Society now advises that it is not good practice to attach adhesive prescription labels from the pharmacist to the Medication Administration Sheets. (MAR). As with the records of newly admitted people, entries should be made by a trained member of staff and checked by a second person for accuracy before they both sign the information. Prescriptions advising medicines to be ‘given as directed’ are not acceptable and should be returned to the pharmacist. When a number of people are involved in administration precise instructions every time are essential. The CSCI had been informed, and this was confirmed by the home, that the provider had recently reviewed and amended the medication polices and procedures in line with good practice and guidance. It was observed that residents and visitors were treated with courtesy and respect. The relationship that staff had with residents was kind and friendly. Privacy and dignity was respected. Brompton House Nursing & Retirement Home DS0000004099.V328331.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. A range of activities and stimulation is provided from which residents can choose to participate and enjoy those they wish. Opportunities are provided so that residents can express their views and make suggestions for future events. Support is given if required to maintain faiths and religious activities, and retain links with the community, family and friends. A good choice of nutritional food is offered so people receive food they need and enjoy. EVIDENCE: An activities organiser was employed to work in the home for 35 hours each week. A monthly programme was presented and displayed. The inspector was told that the variety endeavoured to meet the interests of all abilities and interests. Individual support was given to those who preferred not to participate in group activities. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 14 Each care file contained information and guidance for staff regarding the individuals’ interests and preferences. It was recommended that records of participation and interaction also be maintained. The questionnaire responses indicated that the range of activities was appreciated by most respondents and residents were able to make their own decisions regarding participation. Comments made included: ‘We are given a list of monthly activities, but these are not always carried out as arranged and when the project co coordinator is away no one takes her place on a regular basis. I do appreciate the monthly Communion service arranged and taken by the local vicar.’ ‘A monthly list is provided but usually I do not wish to participate.’ ‘Activities are generally very good.’ ‘Not enough entertainment.’ It would be nice if there were more trips arranged for disabled people in wheelchairs. The home does not have transport suitable for people in wheelchairs. None the less the activities co-ordinator said that transport was hired and four outings a year were arranged. Ideas and views were obtained from residents individually and during the bimonthly residents’ meetings. A newsletter was also published every few months. Currently the residents in the home were Roman Catholic, Church of England or agnostic. Support was given to those who needed assistance. Regular links were maintained with the local Vicar and Priest, and regular Holy Communion and interdenominational services were held in the home for those who wished to attend. Visitors were able to come to the home when they chose and the visitors’ book indicated that a steady stream came during the day. It was observed that they were welcomed and a good relationship existed between them and the staff. The records and questionnaire responses indicated that links were maintained. The home had recently appointed a new chef and it was considered that the standard of catering was improving and the chef’s interest in individuals’ needs was proving to have improvements in appetites and health. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 15 The sample menus provided to the CSCI indicated that a varied and wellbalanced choice of menu was offered and food and fluids were available to residents at all times. The questionnaire responses indicated individual views as follows; Two people said that they always liked the food, five said that they usually did, and one person said that they sometimes did. The comments demonstrated a range of views and included; ‘They are rarely hot enough.’ ‘There is room for improvement.’ ‘The meals are very nicely presented and cooked. Thank you.’ ‘On the whole meals are acceptable. More variety is needed and perhaps a monthly menu worked out. It is good that one can either eat in the dining room or in one’s own room. The chef is willing to offer a choice and listens to suggestions and does his best to meet requirements.’ ‘One of my principle needs when I can to the home was ‘nutrition’ and recovery of my appetite and ability to taste food. To meet my difficulties the chef came to me to discuss what I felt I wanted and to offer his suggestions for helping me. He has checked with me several times since to confirm I am satisfied. Although the two alternatives are offered in the menu for the main meals each day I have been told that I can ask for anything I want. Even at short notice. I have found this very helpful indeed.’ ‘The meals are of a poor standard and often served cold.’ Staff demonstrated an awareness of each person’s likes, dislikes and needs. Records were maintained of what was provided. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Information and support is available so that residents are confident that any concerns they raise will receive an acceptable response. Staff are well recruited and receive induction training so that residents are protected. EVIDENCE: All residents received a copy of the complaints procedure in the Service Users’ Guide when they moved into the home. In the questionnaire responses seven residents said that they were aware how to make a complaint and eight relatives said that they were aware of the procedure. The CSCI had received no complaints, concerns or allegations concerning the service since the last inspection. The pre-inspection questionnaire completed by the registered manager indicated that the home had received seven complaints, two of which had been partially warranted. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 17 An assessment of the complaint record in the home provided evidence of these complaints. Two complaints had concerned violence and aggression by a resident against a member of staff, one moving and handling issue, two complaints concerning the catering, one complaint concerning care practice, and one complaint concerning the drains. The records indicating investigation, action taken and response to the complainant were not available. Although the required documentation was not available for inspection it was observed that each month the organisation required the registered manager to submit an account of complaints received. A resident who spoke to the inspector was articulate and confidently expressed her views. Staff were clear what action they should take if in receipt of a complaint and the comments from questionnaire respondents indicated that they were confident of a response and action to any concerns they might raise. Therefore, although the lack of records is a concern as it fails to provide evidence of investigation and action and is in breach of the regulations, overall the residents and their supporters were confident that their concerns would be listened to and acted on. Comments in the questionnaires included: ‘The home’s manager is a visible presence around the home and willing to listen to comments and suggestions.’ ‘The home manager has made periodic visits to ask me how I am progressing and if I am happy.’ Staff are well recruited. Assessment of three sets of staff documents demonstrated that an acceptable recruitment procedure had been used and appropriate checks made before posts were offered. Induction training had been undertaken and this had included some training in identification and response to suspected abuse of residents. It was considered that this training was basic and all staff would benefit from further training in greater detail. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 18 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, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents have access to clean, comfortable accommodation that suits their needs. Weaknesses in infection control procedures and lack of storage space increase the risks to people in the home. EVIDENCE: A partial tour of the home was undertaken and it was observed that it was clean and tidy with no offensive odours detected. However a mixed response was received in the residents’ questionnaire responses. Five people said that it was always fresh and clean and four people said that it usually was. Comments made included: Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 19 ‘I have found no basis for complaints.’ ‘On the whole housekeeping staff do a good job. Laundry sometimes gets lost or put in another resident’s room. For me it is over heated but realize there are frail residents only sitting around.’ ‘Some cleaners are better than others. More supervision and instruction required regards bed making, bathrooms, toilets etc.’ ‘House keeping standards can some times drop to a poor level.’ A relative stated that she sometimes used her mother’s ensuite facility and always found it to be ‘spotless’. Generally infection control measures were observed to be in place. Personal protective equipment was available and in use. Bathrooms and toilets were provided with liquid soap and disposable towels. The home had a contract with a clinical waste disposal firm and there was adequate equipment available for its collection. In one communal bathroom it was observed that there were three containers of a skin cleanser/protection cream. They were unlabelled so their ownership could not be identified. The use of such products should be individual and therefore it is essential they are returned to their owner’s bedroom after use and not left in communal facilities. There had recently been a problem with the drains that were buried in a floor that extended through a corridor and the laundry. This had required major work and subsequent damage to the floors and floor coverings. The drains and floors had been safely repaired and an insurance claim had been submitted. The inspector was told that the corridor would be recarpeted as soon as possible as it had become a tripping hazard. A requirement was made following the previous inspection that ‘The home must remove all bolts from doors and use a safer lock as a means of securing the doors.’ It was observed that this had not been done. The inspector was told that for a period the home had been without a maintenance person. This post had now been filled and the requirement would be addressed. Storage provision in the home was poor. It was observed that large pieces of equipment were stored in bathrooms when they were not in use. The laundry and sluice rooms were very small. Access to the hand basin in the laundry was blocked by equipment. The room was equipped with two commercial washing machines and one tumble dryer. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 20 This provided no backup should the tumble dryer break down. It was recommended that a reserve machine would be of use especially if a break down coincided with poor weather. There had been on going work to upgrade the main kitchen. Staff said that with the correction and supply of pieces of catering furniture/fittings matters were slowly improving and the kitchen was becoming easier to use and maintain. It was observed that residents had access to lovely gardens. The main garden was raised and accessed from an upper floor via a bridge that was also large enough to use as a patio area. A green house was available and part of the ground was converted to an allotment where home-grown vegetables were raised for consumption in the home. In addition there was an enclosed courtyard garden that was attractively designed and furnished. An aviary for canaries provided additional interest for the residents. Brompton House Nursing & Retirement Home DS0000004099.V328331.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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Suitable staff are recruited and trained but there are insufficient people at times to provide the care residents want/need in a timely manner. EVIDENCE: The home employed eight trained nurses, twenty-five care staff and fourteen ancillary staff. The pre-inspection questionnaire indicated that the home adhered to the staffing notice. However concern was expressed by several questionnaire respondents and staff who spoke to the inspector. Comments made were: ‘When buzzer is pressed staff can sometimes take 20 – 30 minutes to attend. ‘ ‘I have found the carers very good and helpful and can ask for as much care as I need which can vary a little as to how I am. Nursing staff are excellent. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 22 ‘I have met no difficulties. The staff of the home always aim to be as helpful as possible towards me, and I have found the general atmosphere of the home to be very reassuring.’ ‘I have not had any of my requests or questions ignored or neglected.’ ‘The staff are very helpful and nothing is too much trouble for them.’ ‘I can get attention by pressing the call button system at any time day or night and if the person responding to my call cannot deal with the situation further assistance is very quickly brought. Response for me has always been prompt, usually within a minute or so.’ ‘There is no deputy manager, so at the weekends only carers, not always a full compliment, and one nurse are on duty. Also manager’s office and admin. and reception office are closed so no one is available to welcome visitors. Most visitors say they have a warm welcome on other days and can come at any time.’ ‘Bells not always answered very quickly’. ‘It depends on the time of day. One sometimes has to wait half an hour in the morning.’ ‘I think a senior member of staff should be on duty at weekends.’ ‘I am conscious of fewer staff at week ends (or so it seems).’ The inspector was told that the currently dependency levels were high and this was confirmed by information in the pre-inspection questionnaire. Staffing levels had been decreased from eight carers on duty in a morning to seven. The sample duty rota submitted to the CSCI confirmed this. This placed pressure on the staff and they were unable to respond to residents as swiftly as the residents needed. The pre-inspection questionnaire said that twenty-five staff had left the home since the last inspection. Recruitment had been successful as at the time of the inspector’s visit there were only vacancies for a deputy manager and sixtysix night care hours. However the comments indicated concern that there were not sufficient staff on duty at times to meet the needs of everyone. There was a diverse staff team with fourteen staff having come from abroad. Language skills varied and had an impact on some training but overall there were few communication difficulties. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 23 The pre-inspection questionnaire stated that only 20 of care staff had National Vocational Qualifications. However two were awaiting verification and five were currently on courses. The Educational Co-ordinator said that they had reach the required 50 in the past but unfortunately some of the qualified staff had left. The pre-inspection questionnaire indicated that a range of training had been provided in the past twelve months. A new training and development system had been introduced to the home. Induction files based on Skills for Care National Occupational Standards, and training booklets were available for all roles. A full training matrix was being completed so that achievements were clearly demonstrated and needs identified. An assessment was made of three sets of staff records and these contained evidence of an acceptable recruitment process and on going training. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 24 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, 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 so that the residents receive the care they need from good staff in a safe environment. EVIDENCE: The home was managed by an experienced and trained registered manager who is supported by a team of trained staff. There had been a vacancy for a deputy for some time while a suitable person was sought. The manager is well thought of and her expertise is valued. Comments made were: Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 25 ‘Amanda Francis runs a very caring home. My mother has been at Brompton House for just over a year. A large percentage of the staff have been there through this period. Which reflects the good atmosphere.’ ‘Brompton House is run most efficiently by Sister Amanda Francis.’ ‘I am particularly impressed by the way Amanda Francis runs Brompton House. It is clear she expects and receives a high standard and encourages people to work as part of the team. I know my sister is in safe caring hands.’ Residents and relatives are affected by the lack of an identified leader at weekends. Comments made in questionnaire responses were: (Do you know who to speak to?) ‘Yes except at weekends when the boss is not here.’ ‘Staff (needed) in the office at weekends.’ ‘I think a senior member of staff should be on duty at weekends.’ ‘Do think someone in charge should be available at weekends.’ The organisation undertook a Customer Satisfaction Survey with the residents in the home each year and it was observed that the results were published and available. The inspector was told that the home was required to develop an action plan in response to the findings of the survey. This ensured that the service was continually working to respond to identified weaknesses, and develop the quality of the service further. Although not identifiable as a quality assurance system it was observed that systems were in place to audit a range of matters on a continual basis through the year. The home did not hold money in the home for residents. Residents and relatives were able to deposit money from which withdrawals were made after invoices for expenditure were received. For example the hairdresser and chiropodist were paid by cheque and the individual sums were subtracted from the appropriate accounts. Receipts were given and retained for income and expenditure and records were maintained. Staff records indicated that annual appraisals were undertaken. However staff were not receiving individual formal supervision (1:1 support) sessions. These should be provided six times a year. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 26 The inspector was told that the trained nurses had undertaken training and were now going to support an allocated group of staff and also assist in the further development of the key worker system. The handy man demonstrated that he maintained meticulous records of the checks, maintenance and servicing that he carried out. He had recently undertaken the Fire Awareness Course and was responsible for Fire Safety Checks and staff training in this area. It was observed that there was a Fire Risk Assessment available for the home undertaken on 04.11.03 and reviewed on 20.11.06. Fire safety checks had been regularly undertaken and the system was receiving a routine service on the day the inspector visited the home. Staff were receiving training twice a year as the handyman had been advised on the course. However the Hereford and Worcester Fire Authority for many years have advised that staff receive a training update every three months. It was therefore recommended that the frequency of this training be increased. It was also advised that attendance be closely monitored to ensure full participation. Risk assessments were available for all departments in the home. Staff were receiving training relating to health and safety matters. Accidents were well recorded and notifications had usually been made to the CSCI when accidents occurred. However it was observed from the records that some notification had not been made as required. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 27 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 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 28 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 OP7 Regulation 15 Requirement Care plans must be available that describe how every identified need will be met. Care plans must be drawn up with the involvement of the resident or with their consent their supporter and be dated and signed. 3 OP11 15 The residents’ wishes concerning their end of life care and arrangements after death must be sought and recorded. 4 OP16 17 In addition to a record being made of all complaints received by the home there must be a record of the action taken by the registered person in respect of each complaint. 5 OP26 13 Infection control procedures should be observed at all times. 30/03/07 30/03/07 30/06/07 Timescale for action 30/04/07 2 OP7 15 30/04/07 Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 29 6 OP38 13 The home must remove all bolts from all doors and use a safer lock as a means of securing these doors. This requirement had not been met within the timescale of 10/01/06 30/04/07 7 OP27 18 Staffing levels and skill mix must be appropriate to meet the needs of the residents at all times. 30/04/07 8 OP36 18 People who work in the home should be appropriately supervised 30/04/07 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 OP22 Good Practice Recommendations It is recommended that efforts be made to identify/ provide appropriate storage for large items of equipment. 2 OP30 It is recommended that staff receive updated training in regard to the abuse of vulnerable people to support the training they have already received. 3 OP38 All staff should receive fire safety training in accordance with the guidance given by the Hereford and Worcester Fire Authority. Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Brompton House Nursing & Retirement Home DS0000004099.V328331.R01.S.doc Version 5.2 Page 31 - 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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