Inspection on 21/10/05 for Brook House

This inspection was carried out on 21st October 2005.

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

Brook House 15/07/08

Brook House 06/05/08

Brook House 18/12/07

Brook House 18/09/07

Brook House 07/11/06

Brook House 05/05/05

Brook House 07/12/04

Brook House 11/05/04

Brook House 02/02/04

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

CARE HOMES FOR OLDER PEOPLE Brook House 72 High Street Riseley Bedfordshire MK44 1DT Lead Inspector Katrina Derbyshire Unannounced Inspection 21st October 2005 11:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brook House DS0000014887.V260486.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. Brook House DS0000014887.V260486.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brook House Address 72 High Street Riseley Bedfordshire MK44 1DT 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) 01234 708077 01234 709712 Riseley Beds Limited Mr Colin Jones, Ms Helen Constant, Mr Brian Constant Mrs Lesley Honeywood Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Physical disability over 65 years of age (20) Brook House DS0000014887.V260486.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 2005 Brief Description of the Service: Brook House is a listed building located in the village of Risley in North Bedfordshire. The building was extended during 1995 and now provides accommodation for up to 20 older people. The ground floor is split level the lower part housing two communal areas and the higher level some bedrooms a dining room, kitchen, laundry, bathing and toilet facilities. Access to the top floor of the home is via a staircase fitted with a stair-lift, the remaining bedrooms, bathrooms and toilets are located on this floor. A day care facility for the use of service users and people in the surrounding area is available in an adjacent building. Car parking spaces for several vehicles is available to the front and side of the home. To the rear of the building is a raised garden that is accessed via a slope. The statement of purpose for the home identifies that the home is unable to accommodate service users who are unable to manage the stairs, which connect the split-level lower floors. Brook House DS0000014887.V260486.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 21st October 2005. The Deputy Manager Mrs Noreen Boughton was present throughout the visit. During the inspection several areas of the home were visited and the inspector spent time with many of the residents in one of the lounge areas of the home. The care of two residents was examined in depth by looking at their records and interviewing the residents and staff who look after them. What the service does well: What has improved since the last inspection? What they could do better: There are several areas that the home needs to change to make it better for the residents. They still need to do more work on the way that they write about the care each resident need, this has been raised as area in need of improvement for a long-time and the home must make sure that they make this a priority. They also need to make sure that an assessment for all the residents is done, they need to do this because if they don’t they will not know what the Brook House DS0000014887.V260486.R01.S.doc Version 5.0 Page 6 individual needs of the residents are and in turn will not know exactly the care that they need. Another area is to make sure that the training records of staff are kept up to date this is important as the home needs a system that is clear enough to show that staff have at least completed the training that they must do under law. 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. Brook House DS0000014887.V260486.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 Brook House DS0000014887.V260486.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): 3 The system for the assessment of new residents is not sufficient and put residents at risk of not receiving the care that they need. EVIDENCE: Within the care records of the residents it was noted that a system was in place that followed a pre-printed section system. However the assessment section for one resident had no entries made within the record and others were sporadic in their entries. The need to have a comprehensive assessment is required for all residents, as without this information the home is not clear if they are registered to care for that person or what they need to do to meet the residents needs. Brook House DS0000014887.V260486.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 The care planning within the home remains inadequate, so not all residents receive the individual care that they need. EVIDENCE: It was noted that the care planning system has changed and a structured template format is in use. However the actual entries made by staff onto these care plan templates is not clear on how staff should support each resident in meeting their individual needs. This requirement has been outstanding over several inspections and must be addressed. The improvement needed is concerning the entries made to the paperwork not the type of paperwork used. Medication stocks and records were inspected. The system in place for the ordering of medicines was sufficient to provide a clear audit trail. Staff had received training in the safe administration of medication and the medication administration records were seen to be in order. The stocks of medicines in the home were in the main appropriate to the levels required however it was noted that a limited amount of stock had been kept for to long a period of time and this must be addressed by the home. Brook House DS0000014887.V260486.R01.S.doc Version 5.0 Page 10 Brook House DS0000014887.V260486.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): 12 & 14 The level of activities in the home are good, they meet the social and cultural needs of the resident’s. EVIDENCE: The day centre located within the grounds of the home provides a recreational service to all residents if they choose to attend. Varying activity programmes are available and these are advertised to the residents. Several residents spoke of their attendance and described quizzes, crafts and local trips to the shops for example. The use of advocacy services is also in place and documentary evidence of this was seen within the care records of the residents. Residents spoke of their daily choices in life from choosing the clothes that they wear to what meal option they prefer at mealtimes. Residents also confirmed that the staff would always ask them what their wishes and feelings on matters were so that they felt as if they ‘still had control over their lives’. Brook House DS0000014887.V260486.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): 18 The policies and systems in place to protect vulnerable people are robust and protect the residents from abuse. EVIDENCE: The homes policy for the protection of vulnerable adults was examined, the policy was comprehensive and included how any incident of abuse should be reported. Staff training records also showed that they had attended workshops on this area and they were able to describe the varying types of abuse, which included physical and financial. The home also maintained records of any previous referral made under the local scheme; these records demonstrated that the home had acted appropriately and promptly to the relevant authorities. Brook House DS0000014887.V260486.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): 19, 21 & 26 The home is clean and free of odours making it a pleasant environment for the residents to live in. EVIDENCE: All areas seen during this inspection were clean and no odours were detected. Several of the bedrooms and corridors had undergone refurbishment having been redecorated and the flooring in several areas had been replaced. In addition a previous requirement to repair and redecorate the front windows was noted to have been complied with as these had been replaced. Concern previously raised about easier access to a toilet for the residents from the homes sitting areas remains outstanding therefore this previous requirement remains with an extended date given for compliance. Brook House DS0000014887.V260486.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): 30 The systems in place for the training of staff are good and residents receive support from knowledgeable staff. EVIDENCE: The training records of staff were viewed, some were noted to not be up-todate and several had no entries for over a year. On further examination of other documents and discussion with the Deputy Manager it was confirmed that a variety of training had been undertaken, but the records had not been changed to reflect this. Staff also confirmed that they had attended several training courses and certificates of attendance and qualifications were on display in the front hallway of the home. Training undertaken by staff included NVQ in Care, moving and handling and fire safety training. Brook House DS0000014887.V260486.R01.S.doc Version 5.0 Page 15 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): EVIDENCE: These standards were not assessed at this inspection Brook House DS0000014887.V260486.R01.S.doc Version 5.0 Page 16 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X 2 X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Brook House DS0000014887.V260486.R01.S.doc Version 5.0 Page 17 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 OP3 Regulation 14 Requirement A comprehensive assessment must be undertaken for all service users. The assessment must include all needs, and must be kept under review. (Previous requirement timescale of 30/06/05 not met) Care Plans must be generated from comprehensive assessments, and then this forms the basis for the care delivered and that it is reviewed at least monthly. Previous requirement timescale of 31/03/03, 30/11/03, 30/06/04, 31/03/05 and 30/06/05 not fully met. Medication must not be kept in the home in quantities above what is needed. There must be a system in place that ensures all non-required medication is returned. Toilets must be easily accessible from the communal areas of the building. Previous requirement timescales of 21/03/03, 30/06/04 and 31/03/05 not met. DS0000014887.V260486.R01.S.doc Timescale for action 31/01/06 2. OP7 15(1)a 31/01/06 3. OP9 13(2) 15/12/05 4. OP21 23(2)(j) 30/11/05 Brook House Version 5.0 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brook House DS0000014887.V260486.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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. 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