Inspection on 14/11/06 for Brookdale Nursing Home

This inspection was carried out on 14th November 2006.

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

Brookdale Nursing Home 06/10/05

Brookdale Nursing Home 07/06/05

Brookdale Nursing Home 14/03/05

Brookdale Nursing Home 01/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Brookdale Nursing Home 16 Blakebrook Blakebrook Kidderminster Worcestershire DY11 6AP Lead Inspector Andrew Spearing-Brown Unannounced Inspection 08:10 14 and 16 November 2006 th th 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 Brookdale Nursing Home DS0000004100.V317689.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. Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookdale Nursing Home Address 16 Blakebrook Blakebrook Kidderminster Worcestershire DY11 6AP 01562 823063 01562 823150 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) Alder Meadows Limited Mrs Elizabeth Ann Ruth Baker Care Home 40 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (40), Terminally ill (3) Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one named service user under the age of 65 years in the category of old age (OP). Date of last inspection Brief Description of the Service: Brookdale is a care home for older people, providing nursing and personal care. The home is a traditional Georgian listed property which has been converted to provide nursing care for 40 older persons. Brookdale is situated in a pleasant residential area of Kidderminster, close to local amenities. The home provides accommodation on the ground and first floor, consisting of single and double bedrooms, lounges and dining areas. The home has a garden to the rear of the property. There is adequate parking to the front of the house. Since the last inspection the former deputy manager has become the registered manager of Brookdale. The pre inspection information received by the Commission during October 2006 stated that fees at Brookdale currently range from £447.00 to £458.00 per week. Additional charges are made for personal items such as hairdressing, chiropody (private), newspapers and taxis. Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector from the Worcester office of the Commission for Social Care Inspection (CSCI) carried out this inspection. The focus of any inspection carried out by the CSCI is to assess the outcomes for people who use the service. As part of the overall inspection of the service offered at Brookdale two visits to the home were undertaken. The first visit to the home was unannounced while the date and time of the second visit was planned in advance to ensure that the registered manager was present. The visits lasted a total of about 12 hours commencing at 8.20 a.m on the first visit and 1.00 p.m on the second visit. The last statutory visit to the home, which was also unannounced, took place during October 2005. This inspection takes into account information received by the CSCI since the previous inspection as well as the visits to the home. Prior to the visits a pre inspection questionnaire was posted to the manager requesting certain information. The inspector received the completed document prior to the inspection. In addition to the pre-inspection questionnaire a number of questionnaires were also sent to the home for residents, relatives and other persons to complete. A total of 13 residents questionnaires, the majority of which appeared to be completed on behalf of residents by either staff or their family were returned to the CSCI prior to the inspection. In addition some comment cards were returned from relatives / visitors. Two comment cards were received from General Practitioners. A partial look around the home took place concentrating primarily on communal areas and facilities. The care documents of a sample number of residents were viewed including care plans, daily notes, risk assessments and accident records. Other documents seen included medication records, some service records and some staffing records. The registered manager was present throughout this inspection. In addition to the registered manager the quality manager was also present for the majority of the inspection. In addition to the persons mentioned above discussions took place with one trained nurse, some carers and the cook. Discussions took place with a number of residents throughout the inspection. Brookdale Nursing Home DS0000004100.V317689.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: Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 7 The information included within the service users guide regarding fees and the nursing contribution needs to be reviewed and amended in line with recent changes in the regulations. Care plans need to be updated to ensure that care needs can be met in a consistent manner. In addition risk assessments need to be up dated and reviewed in line with changing care needs or following an incident within the care home. The management and administering of medication needs to be improved to ensure the health safety and well being of residents. Training is provided however gaps were evident regarding some areas of both mandatory training as well as good practice. The recruitment procedures need improvement to ensure that they are fully robust and safeguard residents. The carpet along part of the first floor corridor is badly worn and is in need of replacing at some point in the future before this area becomes a health and safety risk to all within the home. The lighting in some parts of the home was dull and insufficient. A number of health and safety concerns are included within this report. Care staff are required to assist in the preparation of the residents tea on certain days of the week, this brings about a number of concerns which need to be addressed. 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. Brookdale Nursing Home DS0000004100.V317689.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 Brookdale Nursing Home DS0000004100.V317689.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): Standards 1, 3, 4 and 5. Standard 6 is not applicable. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The documentation supplied to residents and or their representatives regarding fees and the nursing contribution needs to be improved in line with recent changes in the regulations. An assessment of care needs is carried out prior to admission although written confirmation of the homes ability to meet identified care needs is lacking. EVIDENCE: A revised copy of both the statement of purpose and the service users guide were obtained as part of this inspection. The service users guide is not available in any other format but the inspector was assured that this would be given consideration such as the availability of it on audiotape. Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 10 Information provided to potential residents needs to be reviewed due to changes made to the Care Homes Regulations, which came into force on the 1st September 2006. As a result of the changes to regulations further information now has to be supplied to residents including matters regarding the nursing contribution payment. Following any additional changes to these documents an amended copy should be sent to the local office of the commission. The previous inspection report noted that the pre admission assessment of a resident was based on the activities of daily living, which was suitably completed and contained sufficient information for a basic care plan to be formulated. The file of a recently admitted resident confirmed these earlier findings. It was evident that family members or residents representatives are able to view the home prior to a potential residents admission. Evidence was not available to demonstrate that persons are given a copy of the service users guide. At the time of this inspection the quality manager had drafted a proposed letter to be sent to residents and or their representative confirming that the home was able to meet care needs as this was not happening. Brookdale is registered to care for up to six persons who may have a dementia type illness. The care of persons with a dementia type illness is specialised therefore making it necessary for staff to received suitable training in order that care needs can be met. Some staff have received training while a date was set for others to receive training; any remaining staff need to undertake training in the near future. Brookdale does not provide intermediate care and has no plans to provide such a service in the foreseeable future. Brookdale Nursing Home DS0000004100.V317689.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): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans need to be up to date and consistent with other information held to ensure that care needs are identified and met. The management of medication needs to be improved to ensure that the systems in place are safe. EVIDENCE: The previous inspection report stated that the requirements from the earlier inspection report regarding care planning had been addressed. A representative sample of care plans and associated documents including daily notes and risk assessments were viewed as part of this inspection. Generally care plans were found to be satisfactory although one area of concern was highlighted and explored in greater detail. The care plan was found to be reviewed on a monthly basis as required however the information regarding the use or not of bed rails was conflicting and confusing. It was also Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 12 apparent that bedrails were used as a means of a resident pulling them self up the bed; this was of concern as this is not the function of this equipment. Furthermore the removal of bumpers to enable the equipment to be used for this purpose brought about a risk of entrapment, which was not risk assessed. The mobility assessment on one care plan was unclear as to the amount of care input needed however the dependency assessment was clearer. This did however raise concerns regarding the consistency of care documentation and therefore could potentially fail to ensure that care needs are suitably met. The nutritional risk assessment of one resident needed to be reviewed as it was showing the person to be at ‘high risk’ however other information seen demonstrated otherwise. No care plan existed regarding an identified need to partake in some exercises following consultation with an occupational therapist although diagrams were available in the bedroom. It was reported that nobody had any pressure sores at the time of this inspection. No pressure reliving policy is in place although residents are suitably risk assessed and it was evident that pressure-reliving equipment is available and used as required. The pressure risk assessment on one care plan was seen to be up dated most months; this is good practice. It was pleasing to note that one resident had a suitable care plan in place regarding a chest infection. It was noted that one resident had a number of falls over a short period of time. It was also apparent to the inspector that these falls had a pattern in relation to the time frame and the location. The care plan did not reflect this information and the risk assessment was not reviewed. Furthermore it was apparent that the identified pattern was not previously noted. As a result no strategies were introduced to monitor falls and to try and reduce further episodes. Documentation regarding bathing was insufficient to evidence that identified personal hygiene care needs are carried out. Records were available for staff to capture this information; these included the daily notes and individual bathing record. Although the lack of recording could not be disputed the registered manager was confident that the periods whereby it appeared residents went un-bathed were not a true account of actual practice. However as residents would not be able to confirm the number of baths provided the home was unable to evidence that suitable bathing had taken place. As part of the inspection the management of medication was assessed. In order to carry out this assessment the storage and recording of medication was examined including the current months Medication Administration Record Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 13 (MAR) sheets. Although the current MAR sheets had only commenced a few days prior to this inspection a number of concerns were noted regarding medication held on both the first and ground floor. A number of gaps were evident on the MAR sheets whereby trained nurses had failed to either sign for medication administered or enter a code if the medication was omitted. If a code is used it must either match the codes given on each sheet or be defined if the code ‘O’ is used. Upon MAR sheets seen it was evident that the code ‘O’ is at times used without further explanation. MAR sheets also indicated that trained staff on occasions failed to record the actual dosage given if medication is prescribed on a variable dosage. As a result of the above concerns the registered manager introduced a weekly audit on medication in between the two inspection visits. Medication training is needed for some members of staff. The previous inspection report stated that medication policies and procedures were under review following changes in the regulations on the disposal of medication. These documents were not viewed however it was stated that they are now in place and in line with the local primary care trust. No report from the supplying pharmacist was available on this occasion. Residents consulted were complimentary regarding the staff at the home stating that they are ‘very kind’. The inspector had no concerns regarding the up holding of residents privacy and dignity throughout the visits. Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 14 and 15. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Activities are provided to stimulate residents where possible to enhance quality of life. Meals served are well presented and nutritious using fresh vegetables where possible to provide a well balanced diet. EVIDENCE: Carers consulted throughout this inspection stated that they believed the level of activities provided to be good. An activities coordinator was employed for 2 days per week (it was anticipated at the time of the inspection that this will be increasing to 3 days). Evidence of trips out to the Sea Life Centre and a garden centre was seen as well as in house events such as bingo, sewing and making Christmas decorations. Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 15 Evidence of the homes ability to meet religious care needs was available. Staff also confirmed that residents are seldom got up in the morning by the night carers. Visitors are able to visit at any reasonable time. Visitors are able to use communal areas such as the lounges as well as residents own rooms as they wish. The inspector joined a small group of residents to have lunch. Residents consulted were complementary of the food offered. The meal, which consisted of lamb chops, boiled potatoes, cabbage, carrots and cauliflower, was well presented and hot. Specialised diets are where possible catered for and liquidised meals are presented in a manner, which appears more appetising. Staff were seen to be assisting some residents in a sensitive manner. The newly appointed cook has devised some new menus which stated that at least two fresh vegetables are to be used daily. Fresh fruit was seen prepared ready for residents to have mid afternoon. Brookdale Nursing Home DS0000004100.V317689.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): Standards 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is a clear and accessible complaints procedure in place. In addition the majority of staff have attended training in relation to adult protection. Together these areas assist in safeguarding residents. EVIDENCE: Brookdale has a complaints procedure, which was displayed in the hallway of the home. The procedure is clear and includes the address of the Worcester office of the commission should anybody wish to raise any matters of concern with the regulator. In response to a question upon the questionnaire issued by the commission prior to this inspection and completed by a small number of relatives all those who responded stated that they are aware of the homes complaints procedure. Since the last inspection the commission has received one written complaint in relation to Brookdale. This complaint was forwarded to the responsible individual to be investigated. A satisfactory response was received detailing the action taken in relation to the matters raised. Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 17 A response to a complainant could not be sought however other records regarding complaints were satisfactory. A number of cards complimenting staff were on display. One card stated ‘ We wouldn’t of had better care anywhere’ while another stated ‘thank you for the care and attention.’ One member of staff gave a good response when asked about the actions she would take in the event of actual or potential abuse of a resident. Although staff who have undertaken an NVQ (National Vocational Training) will of received training in relation to safeguarding adults this training is not afforded to all staff. It was noted that training was recently provided, any employee who did not attend this needs to do so in the foreseeable future. Brookdale Nursing Home DS0000004100.V317689.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): Standards 19, 20, 24, 25 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Improvements to the standard of the environment have continued in order to provide residents with a comfortable place to reside where care needs can be met. Some refurbishment is needed to provide a more comfortable and safe environment. EVIDENCE: A large lounge is provided on the ground floor along with a smaller lounge ‘the snug’ which is available for residents who smoke. Another lounge and a dining area are situated on the first floor. The main lounge was out of use on the first day of the inspection as staff were cleaning the carpet. Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 19 The bedroom doors at Brookdale do not have any lock fitted. Documentation held on each file states ‘ no lock on bedroom door as 24 hour access required for supervision.’ The issue of bedroom locks should be re-evaluated to ensure that residents are afforded the privacy having a lock may provide. The carpet along part of the upstairs corridor is badly worn and in need of replacement. A gap was also noted in the carpet in the upstairs lounge, this was not however a trip hazard at the time of the inspection. The carpet at the bottom of some steps leading down to a bedroom had a small hole in it and needs attention. Some of the tables used over the sitting room chairs in the upstairs lounge were showing signs of wear and tear. Pressure relieving cushions were noted to be in use. Concerns were raised with the registered manager regarding the level of lighting in some area of the care home particular one bedroom where a 40watt bulb was in place. The registered person needs to ensure that all areas of the home are sufficiently bright as to ensure the health, safety and welfare of all persons within the home. Previous inspection reports have highlighted some concern in relation to a sliding door leading into a bathroom on the first floor and its ability to provide privacy while residents are bathing. On the day of the first visit the doors were acceptable and closed reasonably tightly however during the second visit one or both had come of the runners and therefore could not be closed properly, which compromised privacy. Toilets are provided throughout the building, some of which are more accessible than others and some of which are more modern than others. Some toilet areas are therefore in need of refurbishment at some point in the future. Access to the rear garden is poor and in need of improvement to enable residents access this area. Radiators along corridors are not covered, it was reported that these are not used, as the home is sufficiently warm without them. No risk assessments were sought regarding these radiators. The upstairs lounge was cool during a tour of the home it was found that the radiator was turned off. Hot water outlets within bedrooms are risk assessed, as the water is not thermostatically controlled in these areas. Monthly checks of temperatures are recorded often showing that high temperatures are reached one was noted to be 54º C. It was of concern that some conflicting information was seen on one care plan ‘ unable to mobilise without assistance’ and ‘ tends to walk alone.’ It was noted that bath temperatures are recorded as between 35 and 37º C Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 20 which may to too cool for some residents. This needs to be reviewed and recorded in individual care plans Sluicing facilities were discussed during this visit. A risk assessment and suitable policy and procedure in relation to the cleaning of commodes needs to be drawn up and any necessary action need to be considered. It was noted that the laundry was lacking a suitable facility for washing hands after handling soiled items; this needs to be addressed in line with infection control procedures. Brookdale Nursing Home DS0000004100.V317689.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): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Recruitment procedures were found to have a number of short falls, which could potentially place residents at risk. A review of staffing levels especially around tea time needs to take place to ensure that suitable and sufficient numbers are on duty at all times in order that care needs are able to be met. The number of qualified carers employed within the home is above the required standard. EVIDENCE: Staffing levels consist of 7 carers and a registered nurse on the morning shift and 4 carers and a registered nurse on the afternoon shift. It was reported that agency staff are rarely used. Staff working on the afternoon shift need to finish off the preparation of the residents tea 4 evenings per week. This brings about a couple of concerns and therefore needs to be reviewed: Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 22 A reduction in care staff available to care for residents while a carer is deployed in the kitchen both preparing the meal and cleaning up afterwards Infection control and cross infection concerns if persons carrying out personal care tasks also carry out tasks within the kitchen. The files appertaining to two recently appointed members of staff were viewed. It was evident that application forms were in place. The registered manager was confident that a gap in employment on one form was genuine. Evidence was held showing clearance in relation to checks against the PoVA (Protection of Vulnerable Adults) list before employment commenced. The address slip from the CRB (Criminal Records Bureau) was on file and showed the date upon which head office received the clearance. Although verbal references were taken these were not always before the commencement of employment. It was of concern to evidence that written reference are not sought until the member of staff had started work and information is forwarded to head office. In order to comply with the standard and therefore to fully safeguard residents two written reference are to be obtained before employment starts. The registered manager assured the inspector that all carers have received a copy of the General Social Care Council guidelines on conduct. Eleven carers, hold an NVQ (National Vocational Qualification) level 2. As it was reported that eighteen carers are employed within the home the expectation that 50 of carers hold this qualification is exceeded. A new induction training programme was recently introduced which is believed to be in line with the standards set by Skills for Care. As this programme has not yet commenced with any employee it will need to be assessed as part of future inspection visits. The quality assurance manager has a good awareness of the training needs within the home and maintains an up to date training matrix. A number of shortfalls in training were identified although the majority of staff have attended mandatory training. Some staff were in need of refresher training in areas such as moving and handling and fire awareness, however dates were set for this training to take place. Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 34, 35, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is a trained nurse and has extensive experience in order to manage the home effectively. The quality systems in place are good. Some health and safety matters including training need addressing, to fully safeguard residents. EVIDENCE: The registered manager is a first level nurse with extensive experience of working within care homes providing nursing. The registered manager has Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 24 commenced upon the required management training – leading to an NVQ (National Vocational Qualification) level 4; it is anticipated that this training will be completed during 2007. Clear lines of responsibility were evident within the home involving both staff deployed at Brookdale as well as external management. The certificate of registration was displayed in the hallway. The need to remove the category of registration ‘Terminal illness’ was discussed, as this category no longer exists following confirmation from the Department of Health that the category is not required in order to admitted residents with palliative or end of life care needs. In addition the one condition in registration also needs to be removed, as the person concerned no longer resides at Brookdale. A certificate of public liability insurance was on display. Residents personal belongings are insured up to the sum of £500.00. The registered manager stated that the home does not offer any system for the safe keeping of resident’s money. Expenditure occurred for items such as hairdressing is therefore invoiced to residents representatives. The quality manager has carried out an extensive review of the service offered at Brookdale responding as to whether the home is compliant or part compliant. The document seen showed that the quality manager had found most areas to be ‘compliant’. The document shows identified shortfalls and the action taken to address these shortfalls. The organisation regularly carries out surveys amongst residents, relatives / representatives and GP’s to gain feedback regarding the level of service offered within the home. The last staff meeting at Brookdale was undertaken during May 2006, the minutes of this meeting were not available. A meeting with trained staff took place on the 9th October 2006. Written reports as required under regulation 26 completed by the responsible individual into the conduct at the home were available as required. Care plans are held within the managers office, although not locked the door to the office is shut when nobody is working within that area therefore trying to ensure that care plans are secure while at the same time ensuring that staff have ease of access. It was however of concern to discover a communication book within the dining room. Not only was this information freely available to anybody within the home the format was also inappropriate and needs to be reviewed in line with access to records. As highlighted earlier within this report the majority of staff have undertaken mandatory training. Staff training needs are discussed as part of the appraisal Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 25 process. Although the majority of trained and care staff have attended a basic first aid course nobody holds a full first aid certificate. The commission has received notifications regarding events within the care home as required under Regulation 37. Accidents are recorded on appropriate forms in line with Data Protection legislation. The auditing and monitoring of accidents is due to be introduced. A number of health and safety documents were viewed as part of this inspection. The majority of documents viewed were satisfactory. The servicing of hoists was due to take place. The previous inspection was carried out during May 2006 at which time no faults were found. The landlord certificate in relation to gas safety issued in February 2006 stated ‘ventilation not to current standard – not at risk.’ This needs to be followed up to ascertain if any remedial action is necessary. The registered manager assured the inspector that data sheets are in place covering cleaning materials in place within the home. The fire log was viewed as part of the first day of this inspection. It was evident that the fire alarm is tested on a weekly basis (although one instance when this did not happen was noted). Concerns were however highlighted to the registered manager and the quality assurance manager regarding the fact that the alarm was not tested in sequential order. In addition the list of fire break glass points gave cause for further concern as the identification numbers did not match the numbers recorded within the log and upon the break glass point. The registered manager gave verbal assurance that the concerns raised would be address within 24 hours; this was carried out. It was noted that some bedrooms doors do not have intumescent seals. Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 26 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 2 X 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X X X 2 2 2 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 X 2 2 Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 5A 5B Requirement The service users guide and if necessary the terms and conditions must be amended in line with recent changes to the regulations. A letter confirming the homes assessment and the ability to meet care needs must be sent to potential residents or their representative. The registered manager must ensure that care plans are in place and up to date to ensure that care needs are identified and met. The registered manager must ensure that risk assessments contain sufficient detail and kept up to date to enable care needs to be met. The trained nurse must sign for medication given to residents on admission. (The above requirement was Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 28 Timescale for action 28/02/07 2 OP4 14(1) (d) 31/01/07 3 OP7 15 (2) (b) 31/01/07 4 OP8 13 (4) 31/01/07 5 OP9 13 (2) 14/11/06 issued following the previous inspection and found to be unmet during this inspection. This requirement must be met in full) 6 OP19 23 (2) All areas of the home including carpeting must be in good repair and suitable to the needs of persons within the home. The registered person must assess the lighting throughout the building to ensure that it is sufficiently bright to maintain a safe environment for residents and others. The registered manager must ensure that water temperatures and room temperatures are within safe limits while also comfortable to meet individual care needs. Review and risk assess infection control measures within the laundry area. The registered persons must reviewing and monitor staffing levels in particular around teatime to ensure that care needs are met. Recruitment procedures must be robust as to safeguard residents. The registered manager must ensure that all staff undertake mandatory training. The registered manager must ensure that care records and other sensitive documentation is kept secure at all times. (This requirement was made following the last inspection with Brookdale Nursing Home DS0000004100.V317689.R01.S.doc Version 5.2 Page 29 31/03/07 7 OP20 23(2) (p) 31/01/07 8 OP25 13 (4) 31/01/07 9 OP26 13 (3) 28/02/07 10 OP27 18 (1) 28/02/07 11 12 OP29 OP30 OP38 19 (1) 18 (1) 16/11/06 28/01/07 13 OP37 17 31/01/07 14 OP38 23 (4) (A) a timescale of 07/10/05. A similar concern was noted as part of this inspection) The registered manager must ensure that safe systems are in place in line with the homes fire risk assessment. 16/01/07 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 OP24 Good Practice Recommendations Residents should be provided with single action locks on their bedroom doors to provide privacy and means of escape in the event of a fire. Brookdale Nursing Home DS0000004100.V317689.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 Brookdale Nursing Home DS0000004100.V317689.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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