Inspection on 12/06/08 for Brookfield

This inspection was carried out on 12th June 2008.

CSCI found this care home to be providing an Adequate service.

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

Brookfield 31/05/07

Brookfield 24/08/06

Brookfield 30/05/06

Brookfield 02/03/06

Brookfield 18/08/05

Brookfield 29/03/05

Brookfield 28/09/04

Brookfield 08/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Brookfield 7-9 Hayes Road Clacton on Sea Essex CO15 1TX Lead Inspector Helen Laker Unannounced Inspection 12th June 2008 10:30 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 Brookfield DS0000017783.V364290.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. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookfield Address 7-9 Hayes Road Clacton on Sea Essex CO15 1TX 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) 01255 427993 F/P 01255 427993 Mr Jos Dorval Mrs Lystra Dorval Mrs Lystra Dorval Care Home 11 Category(ies) of Dementia (11), Old age, not falling within any registration, with number other category (11) of places Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2007 Brief Description of the Service: The residential service is primarily aimed at older people (over 65 years) who require personal care and assistance. The home is also now registered to admit service users who are diagnosed with a dementia condition. The home has a passenger lift installed to reach the upper floor. Most of the accommodation is within single bedrooms, although one twin room remains in use. The home pre-existed at the time of National Minimum Standards coming into operation on 1st April 2002, therefore the level of toilet and bathing facilities existing at that time remain available. On this basis, these facilities comply with requirements of National Minimum Standards. There is one sitting room and one dining room. There is a small courtyard garden to the rear and a small forecourt for parking at the front of the premises. The home has a statement of purpose and service users guide in place. The current fees are £374.50 a week and additional charges are made for toiletries, hairdressing and newspapers. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out as part of the annual inspection programme for this home. The registered manager was available on the day of the inspection. The inspection focused upon all of the key standards. A full tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment (AQAA) completed by the management of the home and submitted to the CSCI. The AQAA provides an opportunity for the service to tell us what they do well and areas they are looking to improve and/or develop. It is anticipated that some improvement be noted as this contributes to the inspection process and indicates the home’s understanding of current requirements, legislation changes and own audited compliance. Three residents, one health care professional, two staff and the manager were spoken to during the inspection. The CSCI sent feedback/comment sheets to the home for both residents and relatives for completion prior to the inspection. Four have been received from staff, one from relatives and one from a service user and the comments taken into account in the body of this report. What the service does well: What has improved since the last inspection? An activities book has been in place since August 2007 and records service user’s daily activity including those undertaken on a one to one basis or in a group according to service user’s individual choices. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 6 The complaints and adult protection procedures have been reviewed and made more accessible in the home. Improvements have been made to the premises such as decorating and recarpeting. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 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 Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and Standard 6 is not applicable to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment process requires further development to ensure residents are confident that their needs are identified and that staff can be confident that these needs can be met. EVIDENCE: The home has a pre-admission assessment system in place and assessments from recent admissions were inspected. The home was in receipt of Care Management assessments provided by social services highlighting the specific and immediate needs and relevant information for each of these people. The home had also carried out their own admission assessments, which did not fully reflect the needs identified within the Care Management assessments and briefly identified physical ability and dependency needs in personal hygiene, mobility and continence. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 9 The quality of the assessment information varied on who completed the assessment. Further training in this area for staff was discussed with the proprietor. One care management assessment made reference to a service user having sight problems and this was not evident in the home’s pre admission assessment or care plan. The home’s AQAA in the choice of home section does not make any reference to the home’s assessment processes. One service user admitted requiring emergency overnight respite, had not had an assessment done prior to or after admission. This was discussed with the proprietor and irrespective of how short a stay may be the home must evidence assessment processes clarify that they can meet prospective service user’s needs. The home continues to use the same standard letter to the prospective resident informing them that the home can meet their needs. It is important that the letter reflects the home’s practice and for this to be accurate further work is needed to ensure that a satisfactory assessment process is in place to evidence that the home can fully meet the needs of prospective new residents. New residents were noted to have copies of the service users guide. Brookfield DS0000017783.V364290.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Although, the staff working in the home are aware of the health needs of each person, more could be done to accurately record information to monitor individuals current state of health and well-being and to ensure people receive the correct medication. EVIDENCE: Since the last inspection there has been minimal progress in the development of care plans with regard to their content. The manager stated that a move to more person centred care plans is planned but as yet the new paperwork has not been implemented. The AQAA just touches on this stating, “care plans have been made more personal”. Evidence must be made available for this. Care plans remained basic and brief in detail and need to be developed according to the individuals’ Care Management assessment. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 11 Whist the care plans reflected some elements of individually tailored care; the space available on the form still limited the amount and clarity of the information provided. The care and support plans continue to lack essential information relating to behavioural, emotional, social, mental and physical health needs. This was evident in the case of the two new admissions with regard to cognitive impairment, confusion and short-term memory loss. One member of staff spoken with clarified that training is available and has been undertaken and the attention to dating and signing documentation was discussed, as this was not evident in all cases. Risk assessments continue in a tick box format and do not clearly clarify the risks or hazards identified or provide instruction with regard to reducing the risks identified. Some are contradictions, for example, area of ‘personal care ability’ is ticked excellent or good but a comment states ‘requires assistance’. Clear management strategies of risk should be incorporated within care planning arrangements for example: continence assessments did not include preventative measures for risks such as pressure sores. Falls assessments where stated ‘to accompany them’ did not include preventative measures such as how to maintain a safe environment, suitable aids and assistance required. Review of care records identified changing needs, but renewed management strategies were still not incorporated within a new plan of care. This was highlighted at the last inspection also. It is important to ensure staff are informed of the way in which new agreed action for care is to be delivered and outcomes to be achieved. Daily care notes should also be written showing that staff have made reference to the care plans. It is of concern to the commission that the AQAA identifies under what we could do better the comment relating to health and personal care “To continue as we are”. Staff training was discussed with the manager and records reviewed discussed with reference to the above. The management approach of the home has been a concern in previous inspections and this was discussed with Mrs Dorval at the inspection with a view to promoting a more proactive and not reactive approach to the inspection process. Health records indicated prompt referral to healthcare professionals and information received. A District Nurse was spoken to on the day of inspection and was complimentary about how the home worked cohesively with them and generally felt outcomes for the residents she was seeing were good. Relatives commented that communication was usually good from the home and that they felt the healthcare needs of their relatives were usually met. Suitable locked storage facilities were not provided for controlled drugs. A small lockable tin was kept inside the medication trolley. We were informed this tin would be used for controlled drugs. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 12 Although at the time of inspection no residents were on controlled drugs. The inadequacy of the storage facilities was raised at the last two inspections. Since the last inspection the manager confirmed that a new cupboard has been provided. However it was found at this inspection that this was not the case and the manager was advised of the legislation surrounding this and the need to provide an appropriate medicine cupboard as recommended by the Royal Pharmaceutical Society without further delay. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are insufficient staff available at times to offer service users the opportunity to exercise full and flexible choice and control over their lives. Mealtimes are generally a pleasurable experience for service users in a congenial setting. EVIDENCE: On arrival all residents were observed in the lounge listening to music, chatting and watching TV. Music playing at one end of the lounge area was appropriate to the resident group. A daily activity timetable was observed in the staff area at the last inspection which was more task orientated than an individually tailored approach to suitable and appropriate occupation according to peoples choice and preference as and when they required. Monday – Music, sing along and dance Tuesday– cake baking with support Wednesday– cream tea, cake making, sherry morning, shopping for cakes. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 14 Thursday – cards, dominoes, puzzles, papers and magazines Friday– shopping/sea front, dance and exercise Saturday– films, videos and cake making Sunday – sherry morning, socialise and chat. At the bottom of the timetable it states ‘ residents can go out at ay time’. From observation and staff rota, staffing levels are limited to two, most days, it is therefore unclear as to how residents are supported to go out at any time, particularly as staff also carry out cooking duties which may not facilitate service users choices about outings to an optimum level. An activities book has been in place since August 2007 and records service users daily activity via one to ones or group activities according to service users individualised choices. This is progress, as care plans previously did not indicate that residents had participated in any activities nor the outcome or benefit anticipated for the resident. Two residents spoken to confirmed that they had a choice about how they spent their time during the day. The AQAA for the home also identifies a need to “To also have meetings with residents to discuss what they want to do” The Care Management assessment for each of the new residents stated they each required support in maintaining social stimulation and emotional support. Consideration needs to be given to how service users can receive a service tailored to their individual and diverse needs and promote optimal independence. One service user’s social activity assessment stated “has no hobbies and needs no support and very demanding” This was discussed in its individual context on the day of inspection. The service generally still needs to develop more its competence in meeting the needs of residents with varying levels of cognitive impairment. As previously mentioned in this report and the review of care plans that this was evident in the case of the two new admissions with regard to cognitive impairment, confusion and short-term memory loss. We were informed that all staff are currently repeating dementia training as part of this. Menus and food stocks were reviewed and it was found that the use of convenience/processed and value brand foods had decreased. The use of such food products and their high salt and sugar content was discussed with the management at the last two previous key inspections. A dietician had assessed the menus but not residents’ individual nutritional needs. Whilst the dietician previously told the proprietor that the menus were well balanced and suitable for the residents group, she suggested that more variety would be good across the menu and to not to use cheap brand foods for elderly people due to the nutritional content. Following this up from the last inspection value brands were not noted in the home at this inspection. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 15 The home has a two weekly rolling menu and one meal was observed in the home. A choice was offered which was not on the menu and all service users spoken to showed no dissatisfaction with their meals. There was little evidence of fresh fruit or vegetables as stock but we were informed that the last stock had just been used for that meal that week and a new order was to be placed for fresh fruit and vegetables to replenish stocks. Drinks and snacks are available throughout the day. Brookfield DS0000017783.V364290.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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that ensures service users know their complaints will be taken seriously, listened to and acted upon. Procedures in the home ensure people living there can be confident that they are protected from abuse. EVIDENCE: The complaints procedure has been reviewed and updated. It is now displayed where more people can access it along with blank complaints forms in a holder. There have been no direct complaints to the home since the last inspection and it is therefore not possible to assess how effective the manager is at addressing any concerns. One resident spoken to said that they would “be comfortable to raise any concerns with the manager and staff”. All of the service users spoken with commented that they did know how to make a complaint about the home to the manager should the need arise. The proprietor states, in her annual quality assurance assessment, that these are given to all service users and that they are aware of the procedure. The home now has an acceptable adult protection policy in place with the associated local guidance. Staff were able to demonstrate an understanding of Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 17 adult protection procedures. Staff appraisals show that the staff and the manager have identified adult protection as an ongoing training update required annually. The manager confirms in the annual quality assurance assessment that this training is to be addressed. Brookfield DS0000017783.V364290.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): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, people living in Brookfield benefit from a homely environment that is clean and pleasant, although improvements need to be made around maintenance if people are to remain safe. People may be confident that their bedrooms are comfortable and they are surrounded by their own possessions, but would still benefit from an ongoing proactive approach by the manager in order to improve the environment for residents. EVIDENCE: A full tour of the premises was undertaken. At this inspection the nurse call system was working throughout the home. It was positive to note that some bedrooms had been decorated and re- carpeted since the last inspection. This gives a better impression of the home and makes the environment more pleasant for residents. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 19 The downstairs hallway and living room have been re-carpeted since the last inspection and the manager plans to replace all carpets in the bedrooms, where they are poor. The home’s AQAA identifies that daily checks are carried out regarding service users rooms, however a number of maintenance and safety issues were found upon a tour of the premises. These included a tap not working in one room and the pipe under the sink having to be knocked a number of times by the proprietor and a carer before water actually came out of the pipe. A wait of approximately five minutes was then required until the water actually ran through as hot. This was discussed with the proprietor who stated she had had the plumber out and the central heating system had been bled and a suggestion had been made to replace the boiler but because of the price she could not afford it presently whilst re decorating the rooms. The last service for the boiler was noted to have been undertaken on the 1/03/07 and another was booked to be undertaken on the 26/06/08. At the last inspection the manager had been consulting with the local fire authority with regard to access of fire exits whilst making alterations to one bedroom involving installation of an ensuite with a view to making the bedroom a single. This is still under consultation and has yet to be confirmed with the CSCI. This room was also noted to have a blocked fire exit, and although the proprietor states that the fire back authority stated it was alright to do this there was no documentary evidence to substantiate this. In the home’s last inspection report it stated that “Since the last inspection, window restrictors have been fitted to upstairs windows”. This was found not to be the case at this inspection. All upstairs windows in service user areas require restrictors fitting and have not been risk assessed and the proprietor stated she would address this as a priority. The home was seen to be clean on the day of inspection and minimal odours were noted. The home has a cleaner from 7 am to 9 am on weekdays and care staff currently undertake all other cleaning tasks. The detraction from care duties was discussed with the proprietor. Relatives and service users commented that the home could improve with better garden facilities. The garden is a courtyard with no grass verges and looks tired and uninviting. Flowers in the borders were dead and overgrown with weeds and garden furniture needs replacing. Fire safety was reviewed and the checking and maintenance systems were seen to be in place and up to date. The recent fire officer visit showed that some door closures needed attention and signage should be upgraded. It was later confirmed to the CSCI that this work had been carried out. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 20 The home has a satisfactory fire risk assessment in place that was completed by an external contractor in March 2005 and reviewed by a staff member this year. It is recommended that this be reviewed more regularly. There was been no evidence of an inspection since. It was noted in one bedroom at the last inspection that a wall heater was showing signs of getting hot and scorching. This has now been replaced. The laundry is located outside at the rear of the home and work is still underway to improve this area and provide a more suitable environment. The manager states in her annual quality assurance assessment that “the staff have regular staff meetings to check any environment problems” and do check the premises and record anything noted in the ‘occurrence book and repeat this to the manager’. A number of light bulbs that required replacing in one light were pointed out to the manager on the day of inspection. Although a maintenance log is maintained, records are still limited and do not evidence that the work has been done and when. The stairs to the linen cupboard on the third floor were steep and spiral and a risk assessment for staff using them on an ongoing basis should be in place. An assessment of equipment and the environment for access, safety and appropriateness was undertaken on the 23/08/07 indicated, “Access to stairs to private rooms on the second floor should be controlled by gates”. The risk assessment of these is also advised and documentation in place to evidence this. Whilst some systems are in place and improvements are being made a more proactive approach by the manager, to the ongoing maintenance of the premises is required. Brookfield DS0000017783.V364290.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): 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. Residents can feel assured that the recruitment processes of the home do generally have sufficient safeguards in place to they are protected. Improvements in training would help to develop the staff team, which should enhance their understanding of the residents care and improve outcomes for them. EVIDENCE: The home has a stable staffing team. Staffing levels are currently 2 care staff plus the manager am and part pm. 2 care staff late pm and one awake and one asleep at night. On discussion with the manager and the staff, they agree the current dependency levels of the residents and feel that they can meet the needs of the current residents with these levels. The current staff rota was inspected and showed that one member of staff was working from 7.45am to 6pm, six days a week. This was discussed with the proprietor with reference to the working time regulations and the staff members individual contracted hours. This is not considered best practice on an ongoing basis. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 22 The proprietor stated at the last inspection that she plans to employ a cook if the resident levels go up from 7, as at the current time the care staff do all the cooking and cleaning, which does take them away from residents’ physical and social care needs. She stated at this inspection she would be able to employ a cook when the home was at a full complement of 11 residents. The manager needs to keep staffing levels at the home under close review to ensure that residents’ needs are being fully met, especially in relation to outings and social care, which is currently limited. No agency staff have been used in the past three months. The proprietor states in the annual quality assurance assessment that 50 of the care staff have NVQ level 2 and above. Two new members of staff have been employed since the last inspection. Recruitment procedures were checked and found to be generally in good order however one member of staff’s passport had expired since employment and one had no photographic identification. The skills for care induction is being used and was seen for both new staff. No interview records are kept. Following a recommendation from the last inspection that the application form be reviewed in light of the age discrimination act and to give a longer career history and that all new staff should be issued with the general Social Care Council (GSCC) guidelines, the proprietor confirmed this had now been addressed. The home has a policy in place for staff supervision and this should be carried out bi-monthly. Records seen evidence that this is happening and records identify training needs. The manager does not have a planned training programme in place and uses the supervision/appraisal records and staff files to identify need. The AQAA also identifies the home’s need to have “more regular staff training”. Staff training records show that most staff are up to date with mandatory training and have attended some additional training on dementia, falls prevention and health and safety. Staff spoken with confirmed this. The manager needs to work on using the skills and knowledge gained by staff through training to improve services and facilities in the home so outcomes improve for residents. Brookfield DS0000017783.V364290.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): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, Brookfield is run well and people living there can be confident that the home is run in their best interests. Improvements need to be made to health and safety issues if people are to be protected by the home’s procedures. EVIDENCE: The proprietor/ manager confirmed that she has completed the registered managers award but has yet to receive the certificate. Documentary evidence was seen to confirm that her portfolio is currently being reviewed by Anglia University so a certificate can be issued as the company she completed the qualification with had gone into liquidation. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 24 Previously there has been concern that despite undertaking this qualification the manager has yet to put proactive, consistent systems into place which reflect her learning on the course and that would benefit the residents and the home in general. Whilst some steady improvements are being made it remained a concern at the last inspection to the CSCI, the overall management abilities of the current manager. It was felt that the development of the home is often linked to items raised at the time of inspection rather than a proactive management approach by Mrs Dorval the proprietor /manager. This was discussed at this inspection and some further improvements are noted, however the completion of the AQAA was brief and mirrored the Older People Care Standards statements in areas. Although it showed an understanding of the home a more detailed completion would have clarified the home’s development and progress. A basic quality assurance system is in place, which consists of short tick box feedback questionnaires for residents, relatives and visiting professionals. There still needs to be a systematic approach and analysis of results. The questionnaires should help inform and improve practice and facilities in the home. No other audits are currently in place and this is an area for development work in the home. The manager does not refer to quality assurance systems in her annual quality assurance assessment The manager confirmed that at the current time the home does not hold any monies on behalf of residents. Items are purchased on behalf of the residents and then invoices are raised and sent to relatives. A health and safety risk assessment for the premises was completed in August 2007. On further discussion with the manager, there are no other systems in place for assessing health and safety in the home or a risk assessment system. This should be addressed. The manager does identify in her annual quality assurance assessment that ‘a more proactive approach to the management of the home was planned’ but there is no explanation of what this means? Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X X N/A 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 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 Requirement Each resident must have a detailed pre-admission assessment in place and be assured that their needs will be met by the home and how they will be met. This is a repeat requirement from the last inspection 30/05/07 2. OP7 15 31/08/08 The team must continue to undertake further work to ensure that all residents’ health, personal and social care needs are set out in a detailed individual plan of care. This is a repeat requirement from the last inspection 30/05/07 3. OP8 13 Residents’ risk assessments must contain sufficient detail to fully identify the risk and outline management strategies. This is a repeat requirement from the last inspection 30/05/07 Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 27 Timescale for action 31/08/08 31/08/08 4. OP9 13 (2) An appropriate cupboard to store controlled medication must be provided Through assessment and consultation, the team at the home must ensure that residents’ individual social care needs are met and that their independence and self worth is promoted. Social histories of residents should be completed with staff being aware of the content. This is a repeat requirement from the last inspection 30/05/07 31/08/08 5. OP12 16 (2) m & n (3) 31/08/08 6. OP19 13 (4) a, b&c The manager needs to develop a system whereby the premises are regularly checked in relation to maintenance and health and safety. This with particular reference to the water supply and heating of such and the fitting of window restrictors in all areas where service users are at risk. This is a repeat requirement from the last inspection 30/05/07 31/08/08 7. OP27 18 The numbers and skill mix of 31/08/08 staff needs a formal review to ensure that residents’ needs are fully met, especially in relation to social needs and kitchen and cleaning tasks. This is a repeat requirement from the last inspection 30/05/07 The staff-training programme needs to ensure that staff are fully able to meet the needs of residents. This relates to a DS0000017783.V364290.R01.S.doc 8. OP30 18 31/08/08 Brookfield Version 5.2 Page 28 9. OP31 9 consistent approach to training being developed The home must be managed so appropriate management systems in place and ongoing development of services and facilities continue proactively 31/08/08 10. OP33 9,10, 24, 26 This is a repeat requirement from the last inspection 30/05/07 The home must have robust 31/08/08 quality assurance systems in place to help ensure that it is run in the best interest of service users. This is a repeat requirement from the last inspection 30/05/07 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. 2. 3. 4. 5. Refer to Standard OP10 OP12 OP14 OP19 OP27 Good Practice Recommendations Residents care plans should be person centred and detailed enough to ensure equality and diversity issues are covered. Consideration should be given to the appointment of an activities officer to help ensure that residents individual and group social needs are met. Care plans should demonstrate that residents’ choices regarding daily routine have been consulted on and acted upon. The manager should continue to upgrade the premises in relation to the garden. Where staff are working excess hours to those they are contracted for, consideration should be given to ensuring this does not happen on an ongoing basis so that staff practice is not affected by the hours worked? Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 29 6. 7. OP29 OP38 The provision of interview records should be considered. Systems should be in place for assessing health and safety within the home and environmental risk assessments undertaken. Brookfield DS0000017783.V364290.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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