Inspection on 27/06/07 for Brook Lodge

This inspection was carried out on 27th June 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 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 09/10/06

Brook Lodge 02/11/05

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 Brook Lodge Latchen Longhope Glos GL17 0QA Lead Inspector Ms Lynne Bennett Unannounced Inspection 27th June 2007 09:30 Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 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 Lodge DS0000044223.V332944.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 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. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brook Lodge Address Latchen Longhope Glos GL17 0QA 01452 830614 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 Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th October 2006 Brief Description of the Service: Brook House consists of two semi-detached cottages, which have been joined to form one care home. The property was completely refurbished in 2005. 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 in the Forest of Dean. People living at the home have an identified learning disability and may present with challenges to the service. People have en suite accommodation and access to a range of comfortable and homely spaces. They also have the use of an allotment 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. Each person has a copy of a service user guide and a statement of terms and conditions. A copy of the Statement of Purpose and last inspection report is available in the entrance hall. The fee levels for the home range from £793 to £2,200 per week. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place in June 2007 and included two visits to the home on 27th and 28th June. The registered manager was available throughout and the group manager was in attendance for feedback. All people living at the home were met; some were involved in showing their rooms and four people chatted about their experiences of the home. Six comment cards were returned from people living at the home, four comment cards from parents and three comment cards from healthcare professionals. An Annual Quality Assurance Assessment (AQAA) was supplied to the Commission prior to the inspection. Regulation 26 reports and Regulation 37 notifications to us have also provided evidence for this inspection. A sample of records were examined including care plans, people’s files, staff records, medication and financial records and health and safety information. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? A member of staff has taken responsibility for scheduling activities and there has been a significant increase in the opportunities for people to participate in their choice of social, recreational and educational opportunities. One person Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 6 said they enjoy going to college and are looking for a job. Others were observed going out with the support of staff. Menus offer a greater variety of choice, giving an alternative to the main meal. People’s dietary and cultural needs are catered for. Medication systems have improved reducing the risk of error to people from poor administration. Staff are having the opportunity to access a range of training courses specific to the needs of people living at the home such as mental health training and aspergers syndrome. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 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 Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have access to information, which when updated will provide them with an overview of the service enabling them to make a decision about whether it will meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide for the home were last reviewed in November 2006. Copies are provided to people wishing to move into the home. The AQAA states that in the next twelve months these documents will be produced in a format appropriate to the needs of people living in the home with their involvement. After discussion with the registered manager it was agreed that amendments would need to be made to these documents with reference to the gender of people who may live at the home. Although there are presently 9 men living at the home as stated in the Statement of Purpose, the home may provide care to men or women. There have been no new admissions to the home since the last inspection. Milbury/Voyage have produced new assessments for people wishing to move into the home. The registered manager confirmed that these would be Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 9 completed during initial contact. An assessment of need and care plans would also be obtained from the placing authority. This information had been obtained for the last admission and a three-month review had been held to confirm their placement at the home. Visits to the home are encouraged. The registered manager described visits made by a healthcare professional and a manager representing a person considering moving into Brook Lodge. The home currently had two vacancies. Milbury/Voyage produce a comprehensive welcome pack for new people to the home that includes a copy of their terms and conditions. The most recent person to move into the home does not have these documents. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s assessed needs are being identified and met although a more person centred approach would provide greater opportunity for them to be involved in the planning of the care and support they receive. EVIDENCE: The care of three people was examined in depth, reading their care plans, examining their medication and financial records and talking to them where possible about the care they receive. Time was also spent observing them during the visits. A new care plan format had been introduced and this had been put in place for most of the people living at the home. Of the plans examined two were in the new format and one in the old format. People confirmed that they have key Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 11 workers. Key workers monitor and review people’s needs producing a report every six months. People are having annual reviews with their placing authority. The home produces its own review, copies of which were examined. Placing authorities are also supplying a copy of their care plan. For those people involved in mental health services there is evidence of regular contact with a named health care professional and a standard level care plan (C.P.A.) being in place. Discussions with the registered manager centred on how this approach could be made more person centred and she stated that the organisation had been looking at ways of implementing this, starting with staff training. Care plans identify each person’s assessed need in areas that range from their physical, intellectual and emotional to social needs. From these their needs are identified and if necessary risk assessments and Crisis and Aggression Limitation Management (C.A.L.M.) protocols developed. For instance one person has recently been diagnosed with diabetes, care plans are in place to monitor their foot care and their diet and risk assessments identify that regular opticians appointments are necessary. A C.A.L.M. protocol then lists triggers that may upset this person and indicates what techniques staff should use to prevent this escalating. Discussions with staff confirmed their understanding of these issues and observations during the visit verified that this guidance was being put in place. Care plans are not signed and dated so it is difficult to assess whether they are being reviewed. Risk assessments are signed and dated, with evidence of regular review. Restrictions to freedoms are also noted in these plans, giving the reasons why and who was involved in the decision-making. However, taps have been removed from the kitchen and bathroom in the annexe and access to door keys restricted. The reasons for this are not recorded in the care plan. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. People have a nutritional diet and their diverse needs are catered for. EVIDENCE: Since the last inspection a member of staff has taken responsibility for scheduling activities with each person. There has been a significant improvement in the range of opportunities being offered to people. Each person has a timetable of activities in their file and there is a white board in the conservatory that also reflects these schedules. Each day an activities board in the dining room is completed giving information about the plans for that day. Daily diaries were sampled for a two-week period in June and provided evidence that people are having the opportunity to participate in a Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 13 wide range of day and evening activities. Where a person has been offered an activity and refused this is noted. Activities may occasionally be re-arranged due to staffing levels or training. Some staff felt that staff levels could impact on the range of opportunities offered. The weeks sampled did not verify this and the rota for June indicated that staffing levels would be at five or above for each shift. The registered manager said that levels are satisfactory and due to the current rota there are times when there can be up to 9 staff on duty. Daily diaries and rotas verified this. People said that they regularly go for walks around the village, to the church, shop or pub. One person likes to go to the shop for the daily newspaper. They also said that they like to go to Gloucester or Ross on Wye. During the visits they were observed going out for scheduled activities. One person said they were recently supported to go and watch their favourite football team. People like to go swimming, bowling, car boot sales and horse riding. Another person is becoming a keen dressage competitor and photographs of him competing were being prepared to display around the home. One person stated in their comment card that they would like to be asked what they would like to do each day rather than being told. One parent commented that their son is “improving because he is so occupied which is excellent”. Holidays are arranged, one person is looking forward to going to Butlins and others had just returned from a week in Tenby. Comments from healthcare professionals also confirm the home is “creative when planning daytime activities”, “helps people achieve their potential” and “to live the life they choose”. People said that they attend the local college for computer and cooking courses. One person recently joined staff for training at a local home and others will be joining staff for basic food hygiene training in the future. One person is discussing with staff the possibility of finding paid work in the local village. People said that they are supported to keep in regular contact with family and friends. Many keep in touch over the phone, some have staff support on visits and others come to the home. Daily diaries verify regular contact. Regular house meetings are held where people have the opportunity to discuss and make decisions about their day to day activities and any issues about the home. During one meeting people highlighted that some staff did not knock before entering their rooms. Staff were observed knocking during the inspection. People said that they have responsibilities around their home such as helping to clean their rooms and communal areas. People were observed doing this during the visits. People also have the opportunity each week to help to prepare a meal. On the day of one visit some people were making pizza for their lunch. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 14 Changes to the home’s menu are being implemented giving people greater choice, offering an alternative to the main meal. Pictures of meals are being collated along with recipes to give people more information about the meals being provided. The cook said she plans the menu with people living at the home reflecting their likes, dislikes, cultural and dietary needs. A range of freshly produced meals is prepared giving people access to a healthy diet of fresh vegetables, fish, meat and fruit. Meals are recorded in each person’s daily diary and one person maintains a personal food and drink diary. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. Improvements in medication systems protect people from the risk of harm due to errors in administration. EVIDENCE: The way in which people wish to be supported is identified in their care plans. Comments from a healthcare professional state that staff “treat each person as an individual” and “support people to respect each other”. Another healthcare professional commented that the home has “exceeded in the care they have provided”. People were observed being flexible with their routines and being offered support and guidance when needed. People have access to healthcare professionals. Details are kept in their care plans. Appointments are recorded and daily diaries verify when these have taken place. There was evidence that people are referred promptly to their doctor and have regular dentist and chiropodist appointments. One person who has recently been diagnosed with diabetes needs to have an optician’s appointment each year and the registered manager confirmed that this would Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 16 be arranged. Staff have received training in diabetes and the appropriate care plans have been put in place. Staff confirmed that referrals have been made to a dietician. At present the diabetes is controlled through diet. Systems for the administration of medication have improved since the last inspection. The system used has changed to a monitored dosage system for which staff have received training. All staff have completed foundation training in the administration of medication. The deputy manager completes assessments of competency periodically. Satisfactory records are being maintained including stock control, countersigning handwritten entries, labelling liquids and ointments with the date of opening and administration of ‘as necessary’ medication. The temperature of the room is monitored and recorded ensuring medication is kept at the correct temperature. Consent for medication to be administered by staff has not been incorporated into the new care plans. Some staff expressed concern about the use of ‘as necessary’ medication and that where prescribed to calm a person when angry or distressed staff were not following guidelines and giving the medication straight away rather than as a last resort. Guidelines for the use of ‘as necessary’ medication give staff clear instructions on the use of this medication and when it can be given. Records for one person during May 2007 indicated frequent use of ‘as necessary’ medication but this has not been sustained in June. This also coincided with a period of ill health for the person. See also Standard 23. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service feel confident using the home’s complaints procedure in the knowledge that their concerns will be listened to and acted upon. Their rights are not being protected and they are open to abuse due to a failure of staff to implement the home’s policies and procedures. EVIDENCE: The home has a complaints policy and procedure entitled ‘Letting us know what you think’ and each person has a ‘help card’. The home has received 7 complaints from people living at the home over the past 12 months. Each was entered onto a complaints form and actioned by management. They described the outcome of each complaint. This information had not been recorded on the complaint forms in the space provided. The AQAA states that each person will be given personal copies of the complaints procedure and that the home will explore providing this in a format appropriate to their needs. People spoken with said they would talk to staff or management if they have concerns. All comment cards indicated that people are aware of how to make a complaint to the home. Staff and management are scheduled to attend training in the safeguarding of adults. Some of the staff spoken with were unaware of the organisation’s ‘Whistle blowing’ policy and procedure or did not have confidence in using it. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 18 The registered manager said that this is discussed with staff and confirmed that new staff have copies of this as part of their code of conduct. During the inspection a member of staff gave information to us about the conduct of colleagues. Although aware of the ‘Whistle blowing’ procedure they had not used it to pass on information about possible abuse of a person living at the home. This information was passed onto the registered manager and group manager who immediately took action to investigate the matter. Staff receive training in C.A.L.M. and there are protocols in place giving clear guidance on the use of diversion, distraction and as a last resort physical intervention. There has been a considerable reduction over time in the use of physical intervention and records show that staff are being successful with verbal de-escalation. As mentioned there is some concern about the use of ‘as necessary’ medication and management will be monitoring this closely. Each physical intervention is used records are completed to provide information about why it was used. These documents clearly state that we must be informed when physical intervention is used. This has not been happening. Some people are being supported to manage their personal finances. A recent audit by Milbury/Voyage recommended changes to the recording that was in place. These have been implemented. Direct debits were noted on bank statements for one person that incurred an overdraft and additional payment to the bank. This had not been picked up by the home. They immediately investigated this and contacted the bank to resolve the matter. Bank statements from March 2007 onwards do not provide evidence that they have been monitored or checked. Prior to this statements were being signed as they were checked. Some people also have considerable amounts of money in a very low interest bank account and do not have access to a savings account. There are no financial risk assessments in place. The registered manager confirmed that some staff support people to access their money using a card and pin number. It was also noted that some people have been paying for staff meals and drinks. The registered manager confirmed that this is not the correct procedure and said that this would be investigated. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the homes enables people to live in a safe and comfortable environment which on the whole is well maintained. Sustaining a clean and hygienic environment will safeguard the home from the spread of infection. EVIDENCE: Brook House was completely renovated and refurbished in 2005. It 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 bedrooms have a shower and some have a bath with shower unit. There is also a one bedroom self-contained annexe attached to the side of the home. 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. A gazebo provides additional cover for Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 20 people living in the house and annexe. A plot of land to the rear of the home has been purchased with the intention of rearing some animals. People also have access to an allotment adjacent to the house. A greenhouse has recently been erected in the back garden. Damp identified in the annexe has just been rectified and the room redecorated. Several other rooms have been redecorated and people living at the home have been involved in the choice of colour scheme. The registered manager confirmed that communal areas are due for redecoration and people will be involved in the choice of colour scheme. Systems are in place to manage the day-to-day maintenance of the home. One of the en suite shower rooms appeared to be leaking into the main bedroom. This needs to be monitored. The floors had just been washed so it was difficult to ascertain whether this was due to water seeping under the door. At the time of the inspection most parts of the home were clean and tidy. Carpets throughout the house despite being replaced in 2005 are showing signs of wear and tear. Some are stained and despite cleaning are in need of replacement. Several bedrooms had an odour that needs addressing. A mattress and pillows in one room are to be replaced. Staff have just attended infection control training. Personal protective equipment is provided. Communal hand washbasins have liquid soap and paper towels. Contracts are in place to dispose of any clinical waste. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff have access to training enabling them to acquire the skills to support the people who live at the home. Recruitment and selection procedures are not safeguarding people from possible harm. People living at the home are not benefiting from a well supported or supervised staff team. EVIDENCE: The home presently has two vacancies to which it is recruiting. Since the last inspection three new staff have started working at the home. Those spoken with had mixed feelings about the induction programme which is in place. Milbury/Voyage have produced an induction programme which states it is equivalent to the Skills for Care Induction and Foundation programme. Some staff have not completed their induction but others felt it was rushed. The group manager confirmed that the NVQ programme would shortly be run by Milbury/Voyage. There are presently 24 of staff working towards an award, 35 have a NVQ and just over 20 of staff are waiting to be registered. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 22 Staff were observed being accessible to people during the visits and those spoken with had a good understanding of the needs of the people they support. Comments from health care professionals and parents also verified this. One person stated that ‘management and staff have a good rapport with persons they care for’. Recruitment and selection is completed by a central human resources team and interviews of prospective staff done at the home. Some information is kept centrally such as original Criminal record bureau checks and medical questionnaires. A spreadsheet is sent to the home indicating when these documents have been obtained. There was no evidence that a medical questionnaire had been obtained for one person. It was evident that two written references and a satisfactory Criminal record bureau check are being obtained prior to appointment. It was noted that for one person a full employment history had not been obtained and that where another person had previously worked in care the reasons why they had left these positions had not been verified. Some staff confirmed that they have recently attended training in mental health. The registered manager stated that this training would be made available for other staff. Records confirmed access also to training in aspergers syndrome. A new training database is being put in place. A copy of a partially completed matrix was examined confirming that staff are attending training in the next few weeks in mandatory courses such as basic food hygiene, infection control, first aid and health and safety. Additional training is also being offered in the Mental Capacity Act and safeguarding adults. Staff are not able to access Learning Disability Award Framework training at present. The group manager confirmed that all staff will have the opportunity to do ‘low arousal’ training in the near future. Through discussion with staff it was evident that there are some issues around communication within the home. Shift patterns have recently changed and some staff work long days, handovers do not always take place. The registered manager said that she has difficulty arranging regular staff meetings. Supervision sessions have begun to take place with some staff receiving one to one meetings with management in April and/or May. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 and 42. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are involved in the quality assurance system giving feedback about the home. People would benefit from a culture which promotes open communication whilst respecting the confidentiality of information. EVIDENCE: The registered manager has the Registered Managers Award at Level 4 and considerable experience in the field of learning disability. She verified that she is continuing her continuing professional development and maintaining her training in mandatory courses. Milbury/Voyage have reviewed a significant number of policies and procedures in the last six months. There was evidence that staff are asked to read through these and sign a record to confirm this has been done. A number of staff have not read several documents in the home. Some staff were unaware of the whistle blowing policy and procedure. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 24 Milbury/Voyage have a robust system in place for quality assurance which involves people living at the home. Samples of surveys completed by people living at the home and other people involved in their care were seen. A survey was being put together for visitors to the home at the time of the visits. People living at the home also take part in unannounced regulation 26 visits. During the visits confidential information about people living in the home was left in the dining room although a lockable cupboard is provided. The office was also left unlocked and unattended giving access to confidential information. Information about people is also displayed in their rooms. It was not evident whether this was done with their permission. Systems for the monitoring of health and safety are delegated to staff, who will have access to the relevant training. Records confirmed regular monitoring of fire systems, fridge and freezer and hot food temperatures and water temperatures. At the time of the visits open food in the fridges had not been labelled with the date of opening. This was dealt with by the cook when she came on duty. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 1 3 X Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 26 Yes 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 The Statement of Purpose and Service User Guide must provide correct information about the gender of people able to live at the home. People moving into the home must be given a copy of the home’s welcome pack that includes a statement of terms and conditions. They and their representatives must have access to information about the service they will receive. Where restrictions have been agreed with people such as removing taps or keys to doors, reasons for this must be recorded. All staff must have an understanding and awareness of the Whistle blowing policy and procedure and their responsibilities in respect of this in identifying and reporting suspected abuse. Systems must be put in place to ensure that people are protected from possible financial abuse. The Commission for Social Care DS0000044223.V332944.R01.S.doc Timescale for action 30/09/07 2. YA5 5(1)(ba) 30/09/07 3. YA7 17(1)(a) Sch 3.3(q) 30/09/07 4. YA23 18(1)(c)(i) 27/07/07 5. YA23 13(6) 30/09/07 6. YA23 37 27/07/07 Page 27 Brook Lodge Version 5.2 7. YA23 13(6) 8. YA30 23(2) 9. YA34 19(1)(b) Sch 2.6 10. YA34 19(1)(b) Sch.2.4 11. YA36 18(2) 12. YA41 17(1)(b) Inspection must be informed of any incidents that affect the wellbeing of people living at the home including the use of physical intervention. Staff must be aware of financial guidelines this will make sure that people are not put at risk of financial abuse. The environment and fixtures and fittings (including carpets) must be kept in a good state of repair and any odours addressed so that people’s health is not put at risk. The registered manager must obtain a full employment history for all new staff. (This requirement has been repeated from the last inspection). Clarification must be obtained from former employers of the reason why new staff left former positions in care, reducing the risk of possible harm to people. Staff need to receive regular supervision to ensure that good communication is promoted and as a way of monitoring their competency and skills. The registered manager must ensure that information about service users respects their rights to confidentiality. (This requirement has been repeated from the last inspection). 27/07/07 30/09/07 27/07/07 27/07/07 30/09/07 30/09/07 Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 28 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. 6. 7. 8. 9. Refer to Standard YA6 YA6 YA20 YA23 YA23 YA32 YA35 YA36 YA37 Good Practice Recommendations Care plans should be signed and dated so that the review of these documents can be monitored. A person centred approach to care should be adopted to enable people to make decisions about the support they receive. People’s consent to have their medication administered by staff should be recorded in their care plans. Bank statements should be checked regularly and signed and dated when this is completed. People should be enabled to open savings accounts if they wish. The induction programme should be fully implemented in the advised timescales. Staff should be able to access Learning Disability Award Framework training. Staff should have regular access to staff meetings. Staff understanding of policies and procedures should be monitored. Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brook Lodge DS0000044223.V332944.R01.S.doc Version 5.2 Page 30 - 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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