Inspection on 23/05/05 for Brookdell Retirement Home

This inspection was carried out on 23rd May 2005.

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

Brookdell Retirement Home 12/01/09

Brookdell Retirement Home 21/10/08

Brookdell Retirement Home 21/11/06

Brookdell Retirement Home 15/11/05

Brookdell Retirement Home 25/01/05

Brookdell Retirement Home 19/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Brookdell Foreside Barrowford Nelson BB9 6AE Lead Inspector Julie Playfer Announced 23 24 May 2005 10.00 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 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. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Brookdell Address Foreside Barrowford Nelson Lancs BB9 6AE 01282 603224 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Derek Howard Mrs Anna Mary Nicholson Care Home 15 OP 15 Category(ies) of Old Age registration, with number of places Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25 January 2004 Brief Description of the Service: Brookdell is registered to provide accommodation and personal care for up to 15 older people over the age of 65. The home is a mature detached property offering homely accommodation, surrounded by private, attracive and accessible gardens. Garden furniture is provided. The home is located in a fairly secluded position, away from the centre of the village. Accommodation is provided in five single rooms and five shared rooms, which are located on two floors. Access to the first floor is by chair lift. Communal space is provided in two inter connecting lounge/dining rooms. Various aids and adaptations to assist with mobility and self-help skills are available. The home only permits smoking in the conservatory/porch, where seating, but not heating is available. Staff provide 24 hour care in response to individual needs and wishes. Brookdell is situated towards outskirts of the village of Barrowford, however, there are some community resources quite close to the home including a post office, church, public house and the local heritage centre. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one day and a total of 7 hours were spent on the premises. During the visit the inspector looked at written information including records, policies and procedures and spoke with the people who live at the home. The inspector also talked to the manager of the home and the staff on duty. A tour of the building took place both internally and externally. At the time of inspection a total of 12 people were living in the home. What the service does well: What has improved since the last inspection? Residents were made aware of their rights when moving into the home in the form of a statement of terms and conditions of residence or contract if they were purchasing their care privately. Following an assessment of needs, residents received written confirmation that their needs could be met by the home. Care records had been supplemented with risk assessments, which had been carried out in respect to falls, nutrition and pressure sores. The established routines had been discussed and new residents were aware they were free to develop their own routines especially in relation to going to bed. To ensure the staff had access to up to date information the policies and procedures had been reviewed. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 6 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. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 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 standard(s) 1 - 6 The admission procedure was well managed. Residents were provided with appropriate written information and received assurances their needs could be met by the home. EVIDENCE: Written information was available for residents in the form of a service users guide. The guide was presented in a suitable format and readily accessible in all bedrooms. All residents were issued with a statement of terms and conditions of residence or contract, if they were purchasing their care privately. The ‘case tracking’ process demonstrated that residents had their needs assessed prior to admission to the home by a social worker and/or the registered manager. The registered manager had also informed the residents in writing that having regard to the assessment the home was suitable for meeting their needs. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 9 The opportunity to visit the home prior to admission was part of usual practice. However, those residents spoken to said they preferred their relatives to visit the home and make the decision for them. One new resident commented that on her first day, she immediately felt at ease in the home and “everybody had made me feel very welcome”. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 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 standard(s) 7, 8 and 10 Care planning should be improved to ensure the plans fully address the needs of the residents and provide clear guidance to staff on how these needs are to be met. Care practice in the home took full account of the residents’ rights to privacy and dignity. EVIDENCE: From the case files seen, it was evident each resident had a plan of care. However, the plans were basic and did not cover all aspects of health, personal and social care needs. Many of the details were out of date, for instance the last entry for one resident under personal care was dated February 2003. There was evidence of monthly review, but these did not always highlight changing needs and information was sometimes not updated on the care plan. The care plans were supported by care records. However, it was the practice of the home to record significant events, rather than details of daily care and support. The registered manager should therefore increase the frequency of care records, so that changing needs and any recurring difficulties can easily be identified. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 11 The plans did not always fully address the healthcare needs of residents, for instance medical conditions, which had been documented in the social work assessment, were not transferred to the care plan. Hence, the staff had no written guidance on how these needs were to be met. However, discussion between the registered manager and staff suggested that needs were being addressed even though the care plans lacked detail and clarity. This approach is dependent on good verbal communication skills and service users are at risk of not having their needs met, if these informal systems break down. There was evidence that care plans had been discussed with the residents and wherever possible residents had signed the plan and monthly review to indicate their agreement. Appropriate risk assessments had been carried out as necessary, in regard to pressure sores, falls and nutrition. Residents spoken to felt their right to privacy was respected by the care staff and personal care was carried out with respect to their dignity. All residents were referred to by their preferred mode of address, which was documented on the care plan. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 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 standard(s) 12 - 15 Residents were able to exercise choice and control over their lives and maintained good contact with their family and friends. However, since there were few formal mechanisms to allow residents to express their opinions there was little evidence the residents’ views had been acted upon or incorporated into future planning. EVIDENCE: A list of activities was displayed in the hallway. A clothes party had been arranged for the day of the inspection. Other activities included music to movement, aromatherapy, a church service and professional entertainment. The routines in the home were well established and some residents spoken to did not wish to follow alternative arrangements. However, the registered manager had specifically discussed the bedtime routines with new residents, to ensure they felt they could develop their own routine. This was confirmed during discussions with residents new to the home. There had been no Resident’s meetings held since the last inspection and therefore consultation with the residents was reliant on informal conversation. The residents were able to receive visitors at any time and were able to entertain their guests in private. All the visitors spoken to on the day of inspection expressed satisfaction with the standard of care provided by the Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 13 home and many stated how much their relative had improved since moving into the home. The menu was on display in the home and the choice of meals was discussed with the residents prior to every mealtime. The residents were satisfied with the quantity and variety of meals, which were homemade. Drinks and snacks were available at all times and set times throughout the day and evening. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 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 standard(s) 16 and 18 Systems were in place to ensure any concerns of residents would be acted upon. Policies and procedures were in place to respond effectively to any allegations or suspicions of abuse. EVIDENCE: The complaints procedure was incorporated in the service users guide and displayed around the home. Out of date procedures were removed during the inspection. The procedure contained the necessary information should a resident wish to raise a concern with the home or direct to the Commission. The registered manager had received no complaints. The registered manager had a copy of “No Secrets in Lancashire” and an adult protection procedure specific to the home. Minor amendments were required to the adult protection procedure to bring it in line with the “No Secrets” document. The registered manager had a good awareness of the procedure and the response required in the event of any allegations or evidence of abuse or neglect. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 15 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 standard(s) 19 -26 The residents were provided with a clean, comfortable and well- maintained environment. Risks had been assessed appropriately to minimise any hazards to residents’ health and safety. EVIDENCE: Brookdell is a mature detached property, surrounded by its own grounds. The gardens are attractive, private and well-maintained. Since the last inspection a new patio had been put down at the rear of the property. Residents said they enjoyed the gardens and sat out in fine weather. Bedrooms were inspected with the permission of the residents. Many residents had personalised their rooms with their own belongings and decoration was good throughout. The residents said their rooms were comfortable and warm. Residents had been provided with aids and adaptations to assist their independence skills, these included grab rails, handrails and raised toilets. The chair lift accessed the main stairs to the first floor accommodation. However, Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 16 the registered manager was mindful that the home was on various levels and certain parts could only be accessed by negotiating steps. This aspect of the home was pointed out to residents prior to admission and careful consideration was taken of the residents’ mobility during the assessment process. Information about the layout of the home was also included in the statement of purpose. A call system with an accessible alarm was placed in every room, with the exception of the conservatory/porch. This part of the home was a designated smoking area. However, at the time of the inspection none of residents smoked. Should a resident be admitted into the home who smokes the registered person must fit an accessible alarm facility to this room. Since the last inspection the registered manager had maintained a record of water temperatures. This demonstrated the temperature of the water was within the required limits. To minimise the risk of scalding preset valves had been fitted to the baths. Valves had not been fitted to the hand washbasins and risk assessments had been carried to determine if any of the residents were at risk from hot water. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 - 30 The procedures for the recruitment of staff were not robust and must be improved to ensure protection for the people living in the home. Suitable arrangements were in place to ensure staff received appropriate training in line with the needs of the residents. EVIDENCE: Since the last inspection one person had commenced work in the home. The member of staff had completed an application form and attended for interview with the registered manager. However, there were shortfalls in the recruitment procedure, these included gaps in employment history and references received after the person began work in the home. In addition the POVA (Protection of Vulnerable Adults List) and CRB (Criminal Records Bureau) checks were not received until after the staff member started working in the home. The registered manager had devised a training and development programme and suitable arrangements were in place for the induction of new staff. At the time of the inspection 2 members of staff had completed NVQ level 2 and a further 7 members of staff were working towards this qualification. Staff had also received training on Medicine Management by the Primary Healthcare Trust and First Aid. The registered manager maintained a master rota and changes to the hours were recorded in a diary. The level of staffing was in line with guidance previously issued by the Local Authority. However, the registered manager should continue to monitor the night time staffing levels in response to the residents needs. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35, 36, 37 and 38 The staff and residents enjoyed positive relationships, which promoted an open and friendly atmosphere. To safeguard the health and safety of residents and underpin the care provided record keeping must be improved. EVIDENCE: Relationships within the home were good and staff spoke about the residents with respect. The residents valued the help and support they received from the staff, who they described as “kind, caring and helpful”, one person also said “that nothing was too much trouble”. The staff received supervision but this was mostly informal, to ensure the staff are appropriately supervised and supported they should receive at least six formal supervisions a year. Since the last inspection the registered manager had distributed satisfaction questionnaires to the residents (February 2005). The results had been collated and an analysis was displayed in the home. Comments made in the survey Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 19 were positive. The home had previously attained an Investor’s in People Award. Policies and procedures and procedures had been reviewed and the dates of review had been recorded. Appropriate arrangements were in place for handling money, which had been deposited with the home by or on behalf of a resident. A random check of monies was found to be correct. There were shortfalls found in the record keeping, particularly in relation to the care plans and staff records. The registered provider had also not provided the Commission with reports of visits carried out under Regulation 26 since July 2004. The registered manager had arranged to have the bath hoists serviced and ensured hazardous substances were stored in a locked cupboard. The registered manager confirmed the electrical installations had been tested earlier in the year, but she had not received a certificate. The certificate must therefore be obtained as a matter of urgency and a copy of the certificate must be forwarded to the Commission. To ensure the safe movement of residents the registered manager must make arrangements for the staff to receive regular moving and handling updates. Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 2 3 3 2 3 STAFFING Standard No Score 27 2 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 2 3 x 3 1 2 2 Brookdell F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement Individual care plans must set out in detail the action to be taken by staff to ensure all aspects of health, personal and social care needs are met. (Previous timescale of 28 February 2005 - not met). The residents healthcare needs must be fully addressed in the care plan and include clear inforamtion for staff on how these needs are to be met. The adult protection procedure must be amended to closely align with No secrets in Lancashire. The conseravtory/porch must be fitted with an accessible alarm facility, if any resident uses this room to smoke. All records and documentation relating to the recruitment of new staff must be collated and maintained in line with the requirements of the Regulations. Appropriate Police checks must be carried out and received before a person commences work in the home or has any access to the residents. Records required by Regulation Timescale for action 15 July 2005 2. 8 15 30th June 2005 3. 18 13 30th June 2005 Ongoing 4. 22 23 5. 29 17, 19 Immediate and ongoing from the date of inspection. 6. Brookdell 37 17, 19 Immediate Page 22 F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 must be maintained, up to date and accurate at all times. (Previous timescale of immediate - not met). 7. 37 26 The regsitered person must ensure visits carried out under Regulation 26 are completed and documented on a monthly basis. A copy of the report must be sent to the Commission once a month. (Previous timescale of 28 February 2005 - not met). A copy of the current electrical safety certificate must be forwarded to the Commission. (Previous timescale of 28 February 2005 - not met). and ongoing from the date of inspection. Immediate and ongoing from the date of inspection. 30 June 2005 8. 13 38 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 7 12 25 Good Practice Recommendations Residents care notes should be completed on a more regular basis and any concerns monitored. Regular Residents Meetings should take place and minutes documented. Preset valves of the type unaffected by changes in water pressure and which have a fail safe device should be fitted to water outlets on hand wash basins to provide hot water at 43 degrees centigrade. The night time staffing levels should be monitored on an ongoing basis in response to residents changing needs. 50 of care staff should be qualified to NVQ level 2, or equivalent, by 2005. An audit should be undertaken of all staff files to ensure records are collated in line with the Care Home Regulations. Staff should receive formal supervision at least six times a year. All care staff should receive regular moving and handling updates. F57 F07 S9506 Brookdell V225027 2305005 Stage4.doc Version 1.30 Page 23 4. 5. 6. 7. 8. 27 28 29 36 38 Brookdell Commission for Social Care Inspection Unit 4, Petre Road Clayton-le-Moors Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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