CARE HOMES FOR OLDER PEOPLE
Brookdale View 1 Averil Street Newton Heath Manchester M40 1PD Lead Inspector
Geraldine Blow Unannounced Inspection 6th February 2006 08:00 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 View DS0000021536.V279109.R01.S.doc Version 5.1 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.V279109.R01.S.doc Version 5.1 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 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.V279109.R01.S.doc Version 5.1 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 September 2005 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 consistes 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 faciliites 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 dinning room. Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 2nd February 2006. During the inspection time was spent talking to the manager, several of the residents and some members of staff to find out their views of the home. Some relevant documentation was also examined. Since the last inspection the Commission for Social Care inspection (CSCI) had received 1 complaint about the home that was in the process of being investigated. A concern raised by a relative prior to the inspection, was raised with the manager and was actioned. It is commendable that all of the requirements made at the last inspection had been met. During this inspection only a selection of the key National Minimum Standards were assessed. Therefore in order to gain a full picture of how the home meets the needs of residents, this report should be read with the previous reports to gain a full picture of how the home is meeting the needs of the people living there. What the service does well:
The service continued to offer a clean, pleasant environment for the residents who live there. Staff were seen to have good relationships with the residents and appeared kind and sensitive in their approach. A group of residents were seen chatting and enjoying each other’s company in the lounge while having tea and biscuits. The manager was continuing to work hard to improve the service delivered to residents and demonstrated a commitment to meeting the National Minimum Standards. During discussions she was able to identify the individual needs of the residents. From talking to the manager and observations of the inspector it appeared that residents were given choice over their day-to-day routines. One resident told the inspector “the staff are very nice and kind here and do what you ask them to do”. The family of 1 resident had bought her a budgie to keep her company as she was nursed in bed. The manager had details of external advocates who will act in their interests. It was recommended that the details be on display for easy access. Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 6 The home had recently sent out an annual quality audit survey to a percentage of the relatives to try and find out their views of the home and ways to improve the service. This shows that the home is taking the issue of improving the quality of the service seriously and is devoting time and resources to involve people in finding out whether they are succeeding. At the time of inspection the home had not received any replies. From the systems in place it appeared that the financial interests of residents are safeguarded. What has improved since the last inspection? 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.
Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were inspected at the previous inspection. Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 Overall the health and personal care needs of the residents appeared to be met at the home. EVIDENCE: A concern had been raised with CSCI regarding the care of 1 particular resident. Due to the concern this resident’s plan of care was inspected. In the main the plan of care was 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 resident were met. However not all of the identified problems and plans of care had been dated. Appropriate risk assessments had been included but there was no evidence of a risk assessment or consent for the use of bed rails. The plan of care stated that the resident required a pressure-relieving mattress. The manager said that the resident was nursed on Cavalier mattress, which was seen by the inspector when talking to the resident but no
Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 10 documented evidence could be found to support this. The plan of care clearly documented “turn every 2-3 hours”. A turn chart had been implemented but had not been consistently completed. A review meeting had been held with the relatives but there was no evidence that the plan of care hade been drawn up with the involvement of the resident or the family. The resident did tell the inspector that she was happy with the care she received and that the staff “do as I ask them to do”. During discussions with the manager over the concerns raised with CSCI she said that she intended to review the care plan and invite the family to discuss their concerns with her and the qualified nurses on the unit. Evidence was seen of referrals to other relevant health care professionals i.e. Continence Advisor, Dietician, Moving & Handling Coordinator and the Pain Control Nurse. As already stated in this report the standard of care planning had greatly improved and it was obvious the home had worked hard to improve the overall standard. The requirements made at the last inspection with regard to the medication procedures had been met. The remaining core standards were assessed during the previous inspection. Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents were able to exercise choice and control over their lives. EVIDENCE: The requirement made at the last inspection that evidence must be provided that residents are consulted about the programme of activities arranged by the home had been met. From observations and discussions with the manager it appeared that residents were able to exercise choice and control with regard to their day-to-day lives. Residents spoken to confirmed this. Several bedrooms were seen to be personalised with belongings that had been brought in from the residents’ own home. As already stated the home has information regarding independent advocacy services that will act on behalf of the residents. It is recommended that this be put on display for easy access. The remaining core standards were assessed during the previous inspection. Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No judgements were made at this inspection. EVIDENCE: To meet the previous requirement that all staff receive training in the action to be taken in the event of an allegation of abuse the manager said it was an ongoing process. The Southern Cross Trainer had provided some training and a training video had been used. In addition the manager had provided training to some staff. The remaining core standards were assessed during the previous inspection. Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No judgements were made at this inspection. EVIDENCE: The requirements made at the last inspection in relation to the premises, infection control, the cleaning of the hoists, the sluice being kept locked and that waste bins must have lids in situ had been met. The facilities manager was in the process of getting contractors in to repair the water damage to the middle stairwell. The manager said that immediately following the last inspection all loose plaster had been removed. The gate to the ‘skip’ storage area had not been replaced but the procedure now is that any rubbish is put straight into the skip and not stored in this area. The remaining core standards were assessed during the previous inspection. Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Staff have access to the training and learning they require to support the residents accommodated at the home. EVIDENCE: Each member of staff had an individual training record file. In addition the manager had individual training plans for the staff which she was currently updating. The home has a structured Induction process. The Induction is currently based on the TOPPS guidance. However, the organisation that set the standards of training for all social care services and workers recently introduced new guidance on what an induction programme for new staff should include. These new standards will be compulsory in September 2006. The organisation is aware of this new development and the Quality Department is currently reviewing the Induction programme to make sure that it meets the new standards. The remaining core standards were assessed during the previous inspection. Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 15 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 39 The home has the systems and practices to monitor and develop the service based on people’s views. Systems and procedures were in place, which safeguards and protects residents’ financial interests and the home was seen to promote the health, safety and welfare of the residents and staff. EVIDENCE: The registered manager is an experienced Registered General Nurse’s (RGN’s). She appeared both competent and committed to improving the service delivered to the residents. Evidence was seen of an annual quality monitoring system to seek feedback from the relatives of the residents who use the service. The manager is responsible for sending out customer satisfaction questionnaires, which was done late November early December 2005. The completed questionnaires are
Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 16 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. At the time of inspection no feedback had been received by the home. The manager said that the questionnaires are sent out every 3 months to a cross section of relative/representatives and the questionnaire is also on display in the reception area for feedback to be given by any visitor to the home. 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. Policies and procedures reflecting this agreement were in the development stage. Secure facilities were provided for money and valuables held on behalf of residents and receipts were given if possessions were handed over for safekeeping. 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.V279109.R01.S.doc Version 5.1 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 18 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. 1 Standard OP7 Regulation 13 15 17 & Sch 3 Requirement 1. The use of restraints such as bed rails must be thoroughly risk assessed and consent for their use obtained. 2. The plan of care, where possible, must be drawn up with the involvement of the resident in a style accessible to the resident. Once agreed it must be signed for by the resident whenever possible and/or their representative. 3. The responsible individual must ensure that an accurate record is kept of any nursing care provided to the resident, including a record of his/her condition and any treatment i.e. regular pressure relief. 4. The plans of care must contain the date of implementation. Timescale for action 06/03/06 Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 19 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 OP14 Good Practice Recommendations It is recommended that the details of how to contact external advocates be put on display for easy access. Brookdale View DS0000021536.V279109.R01.S.doc Version 5.1 Page 20 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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