Inspection on 02/11/05 for Brook Lodge

This inspection was carried out on 2nd 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 found no outstanding requirements from the previous inspection report, but made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brook Lodge 23/04/08

Brook Lodge 27/06/07

Brook Lodge 09/10/06

Brook Lodge 25/04/05

Brook Lodge 17/12/04

Brook Lodge 28/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Brookhouse Latchen Longhope Glos GL17 0QA Lead Inspector Peter Still Unannounced Inspection 2nd November 2005 09:15 Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 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 Brookhouse DS0000044223.V261532.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 Adults 18-65. 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. Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brookhouse Address Latchen Longhope Glos GL17 0QA 01452 830072 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) Voyage Limited Mrs Jeanie Elizabeth Sherwood Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The present residents of windfall will reside at Hunters Lodge between 20th June and 30th September 2005 25th April 2005 Date of last inspection Brief Description of the Service: Brook House consists of two semi-detached cottages, which have been joined to form one care home now known as Brook House. The care home is one of several residential homes in the area managed by Voyage Homes. Brook House is in a rural location in the village of Longhope, with easy access to Gloucester. Residents have an identified learning disability and may present challenges to the service. Brook House has a large lounge and a comfortable conservatory. On the ground floor there is a kitchen, dining room, activities room, assisted bathroom, WC, office and small medication room. Ten spacious, en suite bedrooms are on the ground and first floor. On the first floor there is also an en suite staff sleeping in room and a laundry room. Some resident bedrooms have a shower and some have a bath with shower unit. There are level gardens and pathways to the front and rear of the property amounting to 0.25 acres. Adjacent to a brook in the rear garden is a pleasant sitting area. Residents have the use of two allotments next to the home where they can grow vegetables. An additional self-contained flat is attached to the property, which has its own entrance and this provides accommodation for the eleventh resident. Residents are about to return to their home following total refurbishment of the property, which has been undertaken to a high standard and includes all new equipment, furniture, fittings and furnishings. Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this announced inspection was to complete a final assessment of the environment prior to residents returning to their home. Residents have been staying in a home twelve miles away, called Hunters Lodge, whilst Brook House, previously called Windfall, was totally refurbished and redesigned internally. No residents were present at the inspection. The cook and development manager supported the inspection, which lasted three hours. The home had been prepared as if residents were living at the home. Beds were made and the dining table laid. The home was decorated with pictures and ornaments, awaiting the resident’s return. A tour of the building and garden area was made and the impression was of a comfortable welcoming home, with good quality furniture and fittings and decoration to a high standard. The outcome of this inspection is that the Commission agree the home will be ready for residents to return to on or after 07/11/05 and on completion of a number of items the provider is attending to. The Requirements listed at the end of this report arose from the last inspection on 25th April 2005 and before the total refurbishment of the building. This inspection only assessed environmental factors and did not look at past requirements. These have therefore been carried forward in their entirety for consideration at the next inspection. What the service does well: What has improved since the last inspection? Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 6 Whilst it was not a part of the inspection, it is understood that requirements and recommendations from the last inspection have been attended to and these will be checked at the next inspection. At the end of this report, they are repeated so the provider can make a check on those points. 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. Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents will be provided with a home which meets their needs and aspirations. EVIDENCE: Not all residents will return to Brook House, since they have chosen to remain at the home residents had moved to during the building works and a resident has moved to another home. Seven residents will therefore initially move back to Brook House. This may actually prove helpful whilst residents become familiar with their home, which has undergone such a significant transformation and is in effect a new care home. Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected EVIDENCE: Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected EVIDENCE: Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected EVIDENCE: Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected EVIDENCE: Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Brook House has become a high quality environment, where careful redesign of the home internally provides a home, which is expected to meet resident’s needs very well. Carpeting of resident’s bedrooms will need review. EVIDENCE: Brook House has a welcoming appearance, and some original features had been retained, the mantelpiece in the lounge being an example. The kitchen has a homely appearance and is close to the dining room, which has a new dining table and sideboard in cottage style. Building Control had provided a completion certificate, concerning the refurbishment works, dated 27/10/05. The home has a new gas heating system installed and was found to be working well. Radiators are all covered and hot water is thermostatically controlled. Three hot water taps were tested and found satisfactory. Lighting is to a good standard and attractive. The spacious independent flat provides for all requirements of independent living, is well furnished, homely and comfortable. The flat whilst attached to the main building has its own front door and is entered externally. The flat has Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 14 a call bell facility for the resident. Whilst there are no other call bell facilities in the home, the system has been designed so that these can be installed wherever there is a future need. Bedrooms comply with national minimum standards regarding the facilities and furniture expected and were ready for occupation on the day of inspection. The bedrooms in the main house are spacious and en suite, supporting independent living and privacy and doors are lockable. It was noted that bedrooms do not currently have carpets and it will be recommended that this be reviewed so that residents can have carpets if they wish. Residents have the use of a phone to use privately within their bedrooms. All bedrooms currently have one comfortable chair and residents will return to the home with a second chair and personal items. Where residents have sufficient furniture of their own, existing furniture will be removed to ensure residents have choice. Each room has a bedside unit, which includes a lockable draw, between four and six power points and a TV socket have been provided. (Power points throughout the home are raised off the floor, providing easy access.) New bedroom, lounge, kitchen and dining room furniture has been purchased and is of high quality. The conservatory and large split lounge had very comfortable chairs and settees. The design of the lounge provides an area with a television and a quiet area. There is also an adjacent activities room, which can be used flexibly. Currently residents do not need specialist equipment, however there is an assisted bathroom on the ground floor and the new laundry equipment includes a machine with a sluicing facility. A COSH cupboard is being installed in the laundry and there is a lockable medication room, containing a lockable metal cabinet, cupboard for files and recording surface. Whilst the room is small, it is considered suitable for the purpose and in a good position within the home. Whilst the home was seen to be in good order, a further ‘deep clean’ will be needed to ensure the home is fully satisfactory before residents return. Some building dust was seen on the kitchen cooker hood and within some resident’s bathrooms. The provider is aware of this and the final clean is within their programme. Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected EVIDENCE: Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 The providers have demonstrated commitment to the provision of a well run home, which, following refurbishment, is in a good position to promote and protect residents health, safety and well being. EVIDENCE: During the transitional period, when residents return, the provider plans to provide extra support to the management of the home. The Responsible Individual, who represents the provider, will visit the home twice a week and the development manger will visit once a week. Requirements and recommendations from the last inspection were not considered at this inspection, and have been repeated so they can be reviewed at the next inspection. It is understood that the provider has resolved the points raised. Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 4 2 3 4 4 3 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Brookhouse Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000044223.V261532.R01.S.doc Version 5.0 Page 18 Not inspected Are there any outstanding requirements from the last inspection? 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 YA1 Regulation 6 Requirement Timescale for action 30/09/05 2. YA5 3. YA14 4. 5. YA17 YA20 The Statement of Purpose and Service User Guide must be reviewed in light of the environmental changes and change of name 17(2)Sch4,8,5(1)b The statement of terms and conditions for each service user must be reviewed to reflect current fees and costs of extras. The name of the Commission must be changed. (Previous timescales of 30/9/04 and 31/3/05 not met) 12(1) 18(1)(a) The registered person must ensure that there are sufficient numbers of suitably qualified staff working at the home to ensure the health and welfare of service users. (Previous timescales of 31/7/04 and 31/3/05 not met) 17(2) Sch 4.13 Full records of meals provided must be kept. 13(2) The home must ensure the safe administration and DS0000044223.V261532.R01.S.doc 30/05/05 30/05/05 25/04/05 25/05/05 Brookhouse Version 5.0 Page 19 6. YA23 37 7. YA23 12(5) 13(4)(c) 8. YA23 17(2) Sch 4.9 9. YA24 24(4)(a) 10. YA24 13(2) 16(2)(l) 11. YA33 18(1)(a) 12. YA33 37 13. YA34 19(1)b Sch 2 1-7 14. 15. YA41 YA42 17(2) Sch 4.12(a) 23(4)(c) (d) control of medication as indicated in the text. The Commission for Social Care Inspection must be informed of instances affecting the well being of service users - such as physical intervention. Risks to the service user remaining at Windfall must be minimised and potential risks to staff must be identified and contingency plans put in place. Service users must have access to their bank accounts and be supplied with records of current balances and transactions with Voyage. The necessary fire equipment must be provided in the self contained flat. Secure storage must be provided for medication and money in the self contained flat. The registered person must ensure that there are sufficient staff employed to meet the needs of the person living in the flat and people living in the temporary residence. The Commission must be informed when staff levels fall below the agreed levels. Staff files must be kept at the home and include all information as listed in the Schedule. Accident and injury records must be stored securely. Regular fire drills and testing of equipment must 25/04/05 31/05/05 25/05/05 31/05/05 31/05/05 31/05/05 25/05/05 25/05/05 25/05/05 25/05/05 Page 20 Brookhouse DS0000044223.V261532.R01.S.doc Version 5.0 16. YA42 23(2)(c) be put in place. Night staff must receive training every three months. Portable appliance testing must be completed. 25/05/05 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. 4 5 Refer to Standard YA6 YA7 YA19 YA30 YA26 Good Practice Recommendations ABC and CALM records should be completed for all incidents. Records of any restrictions in place should be reviewed. Records of appointments with all healthcare professionals should be kept. Provide final clean to home prior to residents returning. (This is a recommendation from this inspection) Review the wishes of residents to ensure they have carpets in their bedrooms if they wish. (This is a recommendation from this inspection) Brookhouse DS0000044223.V261532.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 Brookhouse DS0000044223.V261532.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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