CARE HOMES FOR OLDER PEOPLE
Brookdale View 1 Averil Street Newton Heath Manchester M40 1PD Lead Inspector
Geraldine Blow Key Unannounced Inspection 09:30 12 September 2006
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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 View DS0000021536.V301345.R02.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 View DS0000021536.V301345.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Brookdale View Address 1 Averil Street Newton Heath Manchester M40 1PD 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) 0161 688 7600 0161 682 3004 brookdaleview@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Healthcare Services Limited Laura Ann Riley Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. The home accommodates a maximum of 48 older people. The maximum number of service users accommodated on the ground floor and requiring nursing care shall be 24. Service users requiring personal care only are accommodated on the first floor. Registration is subject to compliance with the minimum nursing staffing levels indicated in the Notice previously served in accordance with Section 25 (3) of the Registered Homes act 1984 issued on 8th October 2001. 6th February 2006 Date of last inspection Brief Description of the Service: Brookdale View Nursing Home provides accommodation for a maximum of 48 older people. The home is able to accommodate 24 older people assessed as requiring nursing care, on the ground floor and 24 older people assessed as requiring personal care only on the first floor. The premises are owned by Nursing Home Properties (NHP) PLC and are leased to Southern Cross Healthcare Limited. The home is situated in the Newton Heath area of Manchester close to a local market, shops, public houses and other social areas and amenities. The home was first registered with the Commission for Social Care Inspection (CSCI) on 30th July 2002. The home consists of a large purpose built building set in its own grounds, which was shared by its sister home operating on the same site. Ample car parking facilities are available. The home offered accommodation in 48 single, en-suite bedrooms. Accommodation for residents is provided on two floors accessed via a passenger lift and stairways. Each floor offers 2 lounges and one dining room. The charges for fees range from £378.84 to £505 per week. The Commission for Social Care Inpsection (CSCI) report is available at the home and through the CSCI Internet site. Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report is based on information gathered by Commission for Social Care Inspection (CSCI) since the last inspection on 6 February 2006 and some supporting information received in the pre-inspection questionnaire submitted by the home prior to this visit, a number of returned residents comment cards and the requirements made at the last inspection. This visit was unannounced and forms part of the overall inspection process and it took place on Tuesday 12 September 2006. The opportunity was taken to look at all the key standards of the National Minimum Standards (NMS) and the requirements made at the inspection on 6 February 2006. This inspection was also used to decide how often the home is to be visited to make sure that it meets the required standards. As part of the visit time was spent with the residents who live at the home, observing how staff work with residents, discussions with the nurse in charge, the administrator, the operations director, a telephone conversation with the Responsible Individual (RI) of the home, some staff members, assessing relevant documents and files and a tour of the premises was undertaken. What the service does well:
The home carries out a pre admission assessments before a resident is admitted to the home to make sure that the home can meet the person’s needs. As found at the last inspection the home continued to offer a clean, pleasant environment for the residents who live there. The staff were seen to be kind and patient with residents individual needs and residents spoken to were positive with regard to the staff. One resident spoken to said, “The staff are very nice and kind”. One returned comment card stated, “The help and support from the staff we receive could not be better”. The home has an open visiting policy and residents and staff spoken to confirmed this. From observations made and from talking to residents it appeared that the privacy and dignity of residents was protected and that residents were able to have choice with regard to their every day life. A choice of meals was available at each mealtime and the residents spoken to, with the exception of one, were happy with the quality and quantity of food. On the day of this visit residents were seen to be enjoying lunch and staff were Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 6 seen giving help to those residents who needed it. Staff spoken to said that drinks and small snack’s were available to residents on request. The home employed an activity co-ordinator and was in the process of advertising for a 2nd part time co-ordinator. An activity board displayed information of various activities, which included a trip to Blackpool, a Halloween masquerade ball, a beach party and a ‘chippy night ‘, every Tuesday, which included a fish and chip supper with a video. Also the home had photos on display of several trips to Southport, which took place over the summer. The home offers training for staff to ensure that they have the necessary skills to meet the needs of the residents accommodated. The home has a robust recruitment procedure to ensure that staff employed are safe to work with residents. Systems are in place to support residents or visitors to make a complaint. Residents spoken to confirmed this. The home looked after residents’ monies safely. What has improved since the last inspection? What they could do better:
No requirements were made at this inspection, however some recommendations were made. To ensure the home is aware of the exactly what the GP has prescribed for residents it is recommended that the home keep a copy of the original prescription. Two recommendations have been made in relation to the recording of medication. The home had a daily menu on display in the main reception area and outside the dining room. However the menu did not reflect the actual meal served. It is recommended that the meals on the menu are the same as the meal served. Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 7 The home provides a variety of activities for residents but it is recommended that the home record what activity each resident takes part in. 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. Brookdale View DS0000021536.V301345.R02.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 View DS0000021536.V301345.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home undertakes an assessment of prospective residents’ care needs prior to their admission. EVIDENCE: The home has a documented pre admission assessment that is to ensure that prospective residents are only admitted on the basis of a full assessment. The nurse in charge and the administrator confirmed that all residents have the pre admission assessment prior to admission and for residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment as well. The administrator said that following the pre-admission assessment the home confirms in writing to the resident that the home is able/not able to meet their assessed needs. The home does not provide an intermediate care service
Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Individual plans of care were in place to ensure that residents’ health, personal and social care needs are fully met. The systems and procedures for dealing with medicines appeared to protect residents. EVIDENCE: A random sample of care plans was examined and as already referenced in this report the requirements made at the last inspection in relation to care planning had been met. The care plans examined had been generated from a needs assessment and the homes own care planning process. Each individual file was found to contain an up to date photograph of the resident for easy identification. Detailed assessments were undertaken on admission and a care plan had been generated if appropriate. The plans of care were found to be detailed, informative and clearly set out the action that needed to be taken by care staff to ensure that all aspects of health, personal and social care needs of the residents are met. Appropriate risk assessments
Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 11 had been included and the plans of care had been reviewed on a monthly basis to reflect changing needs and current objectives for health and personal care. Evidence was seen that where possible the plan of care had been drawn up with the involvement of the resident/representative. The manager sent out letters to the representative inviting them in for a review of the care plan and a general discussion. This was seen as good practice. Each resident was registered with a General Practitioner and evidence was seen of referral to other specialised services according to individual assessed needs for example District Nurses, Tissue Viability Nurse, Dentist, Dietician and Chiropodists. Evidence was seen that the Medication Administration Recording (MAR) sheets were recorded accurately and all deliveries and returns of prescribed medications had been recorded and accounted for so providing a full audit trial. However, it was noted that on a number of occasions Q had been recorded on the MAR’s. The nurse in charge said that was used when the medication was not required. ‘Q’ was not included in the key at the bottom of the MAR. It is recommended that the key clearly describes all symbols used on the MAR’s. A prescribed thickener, which is used to thicken drinks and soups for residents with swallowing impairment had been signed for on the MAR sheet. However the nurse in charge said the MAR sheet did not accurately reflect the correct number of thickened drinks given. In order to ensure that residents care needs are being met a record should be maintained of each drink / soup etc that has been thickened and any other liquid the residents have had to drink. It is essential that the person making the drink signs a sheet, this does not have to be the nurse and it does not have to be signed on the MAR sheet, a separate drinks recording sheet may be constructed for each resident. In addition it is essential that the information for thickening must be accurate. The dietician will give detailed advice and this must be readily available to all staff involved in the preparation of drinks / food for a resident. The nurse in charge said that the GP prescriptions went straight to the dispensing pharmacy. In accordance with the Royal Pharmaceutical Guidelines and to maintian the safey of residents the manager / designated person should ensure that they have a copy of the original prescription to check against the items that were ordered before they are submitted to the pharmacy. From observations made during the inspection and discussions with residents and members of staff it appeared that the nurses and care staff treated the residents with respect and dignity. One resident had a phone in her bedroom so that calls could be taken in private. Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities were provided and residents were able to maintain contact with family and friends. Residents were able to exercise choice and control over their lives and the residents enjoyed the meals that they choose. EVIDENCE: An activity programme and photographs were on display of recent activities and the activity programme appeared to offer a full and varied programme. It was encouraging to note that a “client social history” was completed on admission to the home. It is recommended that the home introduce the use of an individual activity record. Staff and residents said that the home facilitated open visiting and visitors could be received in the residents’ own room or any of the communal areas of the home. From speaking to residents and staff it appeared that residents are able to exercise choice and control over their lives and that residents are encouraged to bring personal possessions into the home.
Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 13 The menu examined demonstrated that the home provided a varied diet, which was nutritionally balanced and included adequate supplies of fresh fruit and vegetables. An alternative to the main meal was available at each mealtime or any reasonable alternative was available to residents. Staff and residents spoken to confirmed this. On the day of this visit residents were seen to be enjoying the lunch provided and staff were seen to be providing assistance to those residents who required it. Residents spoken to expressed satisfaction with the meals with the exception of one resident who said that she didn’t feel all the meals were “home cooked”. It was encouraging that a daily menu was on display. However as already referenced in this report on the day of the visit the displayed menu did not reflect the meal served. Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home encourages and supports people to raise their concerns and complaints and had the policies, procedures and systems in place to protect residents from abuse. EVIDENCE: The home has a complaint procedure on display in the main reception area and the administrator said that the complaint procedure was included in the Service User Guide and all residents/representative are given a copy on admission to the home. A record was kept of all complaints made and included details of the investigation and any action taken. The manager conducts a monthly audit of complaints. This is seen as good practice. Residents spoken to confirmed that they would be happy to make a complaint. One resident said that she had in the past made a complaint to the unit manager, which was “sorted out for her”. The home had a policy for the Protection of Vulnerable Adults (POVA), which accurately reflected the Departments of Health ‘No Secrets Guidance’. The administrator said that each floor of the home had a copy of the policy for all staff to access. Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 15 Evidence was seen of ongoing POVA training and the staff spoken to confirmed that they had attended the training. Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All areas of the home were clean, comfortable, well maintained and equipped to meet the needs of the residents. EVIDENCE: The location and layout of the home was suitable for its stated purpose. On the day of inspection the home was clean, tidy and free from offensive odours. One resident spoken to said that the “home was always lovely and clean”. The administrator said that the home had a rolling programme of decoration to maintain standards. As already mentioned in this report various pieces of new furniture have been purchased since the last inspection. The garden area was well maintained and accessible to residents.
Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and deployment of staff appeared sufficient to meet the residents’ assessed needs. The procedures for recruiting staff were robust and provided adequate safeguards to protect residents. EVIDENCE: At the time of the inspection the home accommodated 34 residents i.e. 11 residents assessed as requiring nursing care and 23 residents assessed as requiring personal care only. The numbers and skill mix of the staff appeared to be sufficient to meet the needs of the number of residents accommodated. The home employed 20 care staff, 3 of which had achieved NVQ level 2 and one member of care staff was currently undertaking the training. Of the remaining staff 7 members of care staff were oversees adaptations nurses who were all currently working through their 12 months work experience before making a decision about undertaking their adaptation training. The staff files examined contained the appropriate documentation as required by Schedule 2 of The Care Homes Regulations 2001. Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 18 Evidence was seen that staff had an individual training record and a computerised matrix was maintained of all staff training. The manager sent letters to individual staff members, informing them when training was due and inviting them to the appropriate training session. This is seen a good practice. The administrator said that all newly recruited members of staff must attend induction training prior to commencing work. A telephone conversation with the Operations Director confirmed this and he said that the induction programme had been updated to reflect the Skills for Care requirements. However on a random selection of staff files and the corresponding training record, evidence of the induction could not be found. It is recommended that evidence of induction attendance is made available. Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service A quality assurance system has been developed to seek residents’ views and the systems for managing residents’ money appeared to protect their interests. The systems in the home appeared to protect residents. EVIDENCE: On the day of this inspection the registered manager was off sick. The Responsible Individual (RI) said that he would keep the Commission fully informed on the situation. Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 20 Evidence was seen of a quality monitoring system to seek feedback from the residents and the relatives of the residents who use the service. The operations director told the inspector that questionnaires are also sent to visiting professionals in order to gain their opinion of the service being delivered. The administrator is responsible for sending out the satisfaction questionnaires on an ongoing basis. The completed questionnaires are sent directly to the company’s head office. Copies are then sent to the homes manager along with comments from head office. If practises were to be changed as a result of the survey the manager would implement an action plan and the information would be cascaded to staff. The operations director said that the manager produces an analysis of the results of the feedback given which is then displayed on the notice board. Evidence was seen that the systems in place did safe guard resident’s financial interests. Southern Cross Healthcare Ltd had a national agreement with CSCI’s Provider Relationship Manager (PRM) regarding residents’ finances. Secure facilities were provided for money and valuables held on behalf of residents and receipts are given. Evidence was provided that the manager ensures the health, safety and welfare of the residents and staff are protected at all times. Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 3 x x 3 Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations 1. It is recommended that staff sign for all thickened drinks/soups given to a residnet and that detailed infomation regarding the thickening is available to all staff. 2. It is recommended in accordance with the Royal Pharmaceutical Guidelines the manager / designated person must ensure that they have have a copy of the original GP prescription to check them against the items that were ordered before they are submitted to the pharmacy. 3. It is recommended that the key clearly describes all symbols used on the MAR’s. It is recommended that the home introduce the use of an individual activity record. 2. OP12 Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 23 3. 4. OP15 OP30 It is recommended that menus displayed in the home reflect the actual meal of the day It is recommended that evidence of induction attendance is made available on the individual staff file or their training record. Brookdale View DS0000021536.V301345.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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