Inspection on 18/08/05 for Brookfield

This inspection was carried out on 18th August 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

Brookfield 12/06/08

Brookfield 31/05/07

Brookfield 24/08/06

Brookfield 30/05/06

Brookfield 02/03/06

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Brookfield 7-9 Hayes Road Clacton on Sea Essex CO15 1TX Lead Inspector Tim Thornton-Jones Unannounced 18th August Final 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. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Brookfield Address 7-9 Hayes Road Clacton on Sea Essex CO15 1TX 01255 427993 01255 427993 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 Jos Dorval Mrs Lystra Dorval Mrs Lystra Dorval Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11), Dementia - over 65 years of age (5) of places Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age (not to exceed 11 persons). 2. Five persons, of either sex, aged 65 years and over, who require care by reason of dementia, whose names were provided to the Comission in March 2004. 3. The total number of service users accommodated in the home must not exceed 11 persons. Date of last inspection 29th March 2005 Brief Description of the Service: The residential service is primarily aimed at older people (over 65 years) who require personal care and assistance. The service was accommodating some service users who require care by way of mental frailty. Normally the home would not be permitted to care for persons with this level of need. However a variation has been made to the current certificate of registration to enable named service users to remain at the home. The names of service users to which this applies have been submitted to the CSCI. The home is not registered to admit service users who are diagnosed with a dementia condition.The care setting is homely in appearance and domicile in its atmosphere and there were suitable levels of equipment available to meet the known needs of service users accommodated. 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 1.4.02, therefore the level of WC and bathing facilities existing at that time remain available. On this basis these facilities comply with requirements. There is one sitting room and one dining room. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to continue a compliance monitoring approach by the CSCI following the previous visit to the home on 29th March 2005. The previous published report for this home occurred on 28th September 2004. The information gathering process for this current inspection was not competed until Monday 5th September 2005. The visit on 29.03.05 concluded that 26 National Minimum Standards were rated below the minimum requirement level. Following this an action plan was agreed with the Registered Persons for a planned improvement. A further monitoring visit was made on 5th May 05 which indicated limited improvement. Further discussion regarding standards was undertaken with the Registered Persons during June 05 when a further commitment was made to improve standards. Following a suitable period of time in which to enable improvement, the inspection to which this report refers was undertaken. This report concludes that whilst some attempt has been made to improve the structure of care management, care workers that are expected to operate the approach did not fully understand how to do so. Care worker deployment, training and supervision, record keeping and the general professional practice observed, remain poor. The environment remains in need of improvement and some aspects of the environment were found to be hazardous and in need of urgent attention. The senior care worker responded to such a matter after inspectors highlighted it. There remains a high proportion of standards not being met and there is a clear continuance of some failing standards that must be addressed. At this inspection 26 standards continue to require improvement to meet the minimum requirements. As a proportion this represents over 68 of all the required National Minimum Standards, which is not acceptable and must improve. Discussion with the Registered Providers and appropriate action will continue to ensure improved standards are achieved and that service users receive safe and appropriate care. What the service does well: The service is in need of considerable improvement to meet National Minimum Standards and this inspection was unable to identify among the standards inspected any aspect that was achieving standards comprehensively. That is Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 6 not to say that some standards were not being achieved well, but were merely not inspected on this occasion. 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. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 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 Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 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, 3, 4 The information available to prospective service users is not current and do not comply with regulatory requirements. Assessment and pre-admission data was not yet adequately managed to ensure that the service was best placed to meet the needs of service users. Services users do not fully benefit from knowing that their needs can be met. EVIDENCE: The Statement of Purpose and Service Users Guide were viewed. Both of these documents were in need of amendment to ensure compliance with Regulation and National Minimum Standards. The Registered Person is advised to consult with requirements via the ‘Care Homes for Older Persons, National Minimum Standards’ documents. The Statement of Purpose refers to the provision of dementia care as part of the service provision, a category for which the home is not registered, although a small number of named service users are receiving care within this category with the knowledge of the CSCI. The guidance contained in relation Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 9 to complaints and Protection of Vulnerable Adults from abuse (POVA) was not in accordance with requirements and therefore the document requires review. The Statement of Purpose refers to the provision of dementia care as part of the service provision, a category for which the home is not registered. The guidance contained in relation to complaints and POVA was not correct and the whole document requires review. The Senior Carer in charge of the home had made considerable effort at the time of inspection, in attempting to understand the level of information gathered and that was known about service users. The files held for current service users all contained assessment information. This covered all the areas identified in standard 3, although in some examples the detail was poor and will need to be developed to provide improved indication of the level of need. These documents, along with the risk assessments undertaken in response to identified needs, would be adequate to provide information that could be used to formulate a care plan and to make decisions regarding the appropriateness of admission. The management of this information therefore is not fully developed to meet the minimum requirement. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 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, 10. • Care management arrangements are underdeveloped and do not meet the requirements and changing needs of service users accommodated for the group of standards assessed. EVIDENCE: The documents marked and identified as ‘Care Plans’ were, in fact, daily records of events affecting the service user. There were found to be documents referred to as ‘bench marks’, which contained statements regarding the expectations of care provision, i.e. a benchmark relating to diet stated that a good intake of protein was imperative, and another relating to respect and dignity stated that they should protect and preserve the service users self esteem. Whilst the statements were all acknowledged and in keeping with good practice, the care plans did not provide any information to the care of service users that would assist staff in delivering the quality statements they contained. What was included was, for the most part, unnecessarily complex in use of language, and of questionable relevance to the service. It was noted that some references within the documentation tended to reflect service provision within a large healthcare setting rather than a small care home. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 11 There was an absence of information on how care workers are to deliver these practices in practical terms on a day-to-day basis. Care workers spoken with at the inspection were unable to demonstrate adequate understanding or the purpose of these benchmarks. In observation, the inclusion of the documents to which this refers caused the care plans, in the opinion of inspectors, to be unnecessarily cluttered with information that deflected from the way in which staff should access appropriate knowledge about service users. Whilst the data and assessment material held should reflect adequately the complexity of care support required for service users, this will need to be understandable and deliverable by staff, who with the exception of a small number of employees, were relatively inexperienced and untrained. On this basis, none of the files sampled contained documentation that would be accepted or recognised as a working care plan. As a consequence, the lack of structure and direction to service delivery appeared to lead staff to working in a way that relied chiefly upon personal and professional intuition rather than an assessed, agreed, planned, recorded and monitored approach. For this reason the service continues to not meet National Minimum Standard regarding care planning and other related standards. This is a matter that must be addressed as a continuing concern. The files of all service users were examined as part of this inspection and evidence of relevant health care assessment and monitoring such as risk assessments for diet, falls and continence was examined. As care plans were not produced in an adequate format or with appropriate clarity, the positive and informative information gathered had not been properly utilised within action plans, which would be the expectation. Records were being maintained of health professional’s visits and their outcomes. From discussion with the Senior Care Worker and via records held on service users files it appears that the homes relationship with some health professionals could be improved to provide a better quality of practice to service users. The practice observed between care workers and service users was variable in practice and the reflection of respect. Whilst some positive examples of practice was discussed with the Senior Care Worker, the tone, language and approach by other staff was observed to be rudimentary and reactive, resulting in service users not receiving the level of professional care and support required by National Minimum Standards. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 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, 13, 14 & 15. • • • • Service users do not benefit from a fulfilled lifestyle. The service has an encouraging approach to visitors and relatives. Service users do not fully benefit from appropriate choices and control. The meals provided meet with service users needs. EVIDENCE: The original assessment of need asks for information regarding service users interests and likes and dislikes. The completion and detail of this element of the document is sporadic, and at best states, for example ‘likes watching TV’ and ‘resting’. There was no indication in any documentation seen of the efforts staff have made in ascertaining service users interests and the success or outcome of these efforts. The opportunity for care workers to support service users in activities and occupation are very limited by the numbers of staff on duty, which from observations during the inspection require them to be undertaking variable practical tasks such as laundry, cooking etc. For a disproportionate amount of time there was evidence to demonstrate that care workers are not always able to attending to service users physical needs. There were demonstrably few Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 13 opportunities for interaction and the provision of activities. As an example, when a staff member was asked what they expected to provide between meal servings, they advised they were to ‘keep an eye’ on service users. Some care workers were unable to demonstrate sufficient skills or experience to engage service users who have more complex care requirements in activities appropriate to their needs. One service users risk assessment for “wandering” identified that regular walks with staff accompanying them was part of their daily plan, however care workers on duty confirmed that there was regularly insufficient numbers of staff to allow this to happen. (See also staffing section of this report). The visits of persons were recorded in the visitor’s book as appropriate. This indicated that friends and relatives attend the home at various times. Staff confirmed that this was encouraged. The inspection concluded that no information was being maintained in relation to advocacy services. In view of the service users who may not have close relatives locally, and in view of their frailty, it is strongly recommended that advocacy services is considered as part of the ongoing review of care planning. Although the meals provided for the week prior to the inspection did not follow the planned menu, they were nevertheless varied and designed to reflect service users preferences. The observation of a lunchtime meal demonstrated that service users enjoyed the meal. All meals offered to service users were recorded on individual sheets, but did not indicate how much had been consumed. In view of the frailty of some service users a record of nutritional and fluid intake is particularly important. During the mealtime service users were observed to eat their meal on trays situated on their laps. This was appeared uncomfortable and inconvenient for some service users by causing a degree of agitation. One service user showed signs of distress by being unable to balance the tray on their laps. The person asked if they should use the dining table, and was told by staff it was ‘up to them’, indicating that carers did acknowledge choice. The service user in this instance was identified as having cognitive impairment and demonstrably found decision making difficult and anxiety provoking. Whilst providing an open choice to service users in this way was a genuine attempt to reflect good practice; for this individual, it was unhelpful and indicated a training need for carers. (See staffing section of this report) Service users were seen wearing disposable aprons during their meal and this appeared as rather institutional. This was an example of questionable practice associated with dignity. The use of the dining room for meals was discussed with the Senior Care Worker, who expressed that service users did not like using the room. This Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 14 should be further explored to identify why service users react in this way and how the environment could be improved. Dietary assessments were conducted for each service user, however the information gathered was not transferred to a care plan. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 15 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 & 18 • Service users do not benefit from the homes practice and procedures relating to complaints and protection. EVIDENCE: A complaint policy was in place and was purchased/obtained via a standardised policy document provider. The content did not meet the expectation of the standard in that it states that only following formal representation to the home can a complaint be raised with the CSCI. This requires review. The complaints policy and associated forms were located within the homes entrance hall. Inspectors were advised that no complaints had been received by the home during the period since the previous inspection, although a logbook was not being maintained to record these when they arise. The CSCI had not received any complaints about this service during the same period. The POVA policy did not adhere to the locally agreed guidance produced by the Local Authority. The document held instructs the service to investigate the allegation of abuse prior to referral to any authority. This must not be done and the document requires urgent review. Care workers have not attended recent training regarding the protection of vulnerable adults and this must be a priority. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22, 25 & 26 • • • • • Service users do not all benefit from a well maintained and adequately decorated environment. Service users do not all benefit from a risk-free environment, clean and with appropriate furniture, fittings and equipment. Service users do not benefit from sufficient washing facilities. Service users do not fully benefit from an environment that is safe. Not all service users benefit from a clean, pleasant and hygienic environment. EVIDENCE: Overall, the environment is domicile in appearance. Several of the rooms visited, however, were in need of improvement to both the decoration (some wallpaper was lifting from the wall in one bedroom) and the quality of furniture. The furnishings and decor were of a ‘tired’ appearance in several Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 17 rooms and the Registered Persons should now address this to avoid further deterioration. On the first floor it was noted that several ceiling lights were not working. These were located above and within the immediate area of the two staircases. One corridor next to a staircase had a step from one level to another. This was not easily located without the use of the lighting and was considered to pose a presenting risk of tripping. The person in charge was advised to make immediate plans to ensure the safety of service users until the electrical fault could be repaired. It was noted again at this inspection that at least one bath on the first floor remains unable to be used by service users due it’s design and location. The number of baths available for use by service users is therefore below that at 31st March 2002 as is required for pre-existing homes (see National Minimum Standard 21.4). Of those rooms that were visited, some were presented as adequately maintained and decorated, although one was considered to have an odour. This will need to be investigated by the Registered Person. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 18 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, 28, 29 & 30 • • Services users do not always benefit from adequately assessed ratios of competent, well trained staff. Service users were not protected by the home’s recruitment practices. EVIDENCE: The home had undertaken an assessment of the staff/service user ratios using a method recommended by the Department of Health. This assessment was based upon service user assessed needs being 2 persons of high dependency, 3 persons of medium dependency and 4 persons of low dependency. This being a total of 9 person’s being accommodated within a registration capacity of 11. Based upon observation of service users, their interaction with care workers, discussion with staff and records available, it was the professional opinion of both Inspectors that the Registered Person should re-evaluate the dependency levels of service users to ensure that adequate levels of suitably experienced and trained staff are deployed. The weekly assessed deployment of 226.50 hours per week appeared inadequate. The staff deployment records were not up to date in terms of validation of their accuracy. Where initials or codes are used, a suitable key should be available to identify their meaning. The staff deployment record was seen covering a three week period, including the week of the inspection. This indicated that one senior staff member had worked for 14 days consecutively and had been rostered for a further 7 days without a day off. The shift pattern throughout this period for the care worker in question was undertaking double shifts on each day amounting to 79.5 Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 19 hours per week. On at least one occasion the worker had undertaken a sleepin duty. This pattern of deployment is unacceptable in that it is likely to increase the risk of errors through tiredness and fatigue. Staff files were sampled. Of the two most recently recruited care workers, neither were recruited in accordance with regulatory requirements. Staff files contained a list of training either having been undertaken or is awaited. This list however, did not reflect the required arrangement of National Training Organisation (NTO) workforce training targets. It is recommended that the Registered Person ensure that there is a staff training and development programme that ensures that care workers are able to meet the changing and developing needs of service users. Whilst some staff have received support training such as food hygiene and fire prevention, inadequate emphasis has been given to care related skills. Staff training should include a programme that provides risk assessment and care planning, POVA practice, interpersonal skills, working with frail older people, recording practice and privacy and dignity as a priority. The competency of staff was observed to be variable with some sound practice being observed. Where variable degrees of skills, knowledge and experience exist, it is not acceptable for service users to receive support in a manner that is widely and notably different according to the individual providing the support at the time. Inspectors observed both good and poor practice within a 1minute period by different care workers with the same service user. The care delivery was observed to be almost entirely intuitive, in that the care plans were unable to be followed, or understood, by the most experienced of care worker. The senior care worker in charge of the home at the time of the inspection was able to demonstrate an understanding of the principles of care planning. It was evident that virtually all of the documents and tools available in the care of service users were not being used in the way they had been intended. There will therefore need to be a further review of the home’s methodology regarding planning, recording and review of care delivery, and adequate training for staff in these principles and practice. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 20 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) 31, 32, 33, 36, 37 & 38 Service users do not benefit from living in a home that is well managed. Service users do not fully benefit from leadership and a management approach that empowers and enables staff to support service users appropriately at all times. The inspection concludes that the home is not always run in the best interest of services users. Care Workers were not adequately supervised. The home’s record keeping, policies and procedures did not always safeguard Service users rights and their best interest. The health and safety of service users was not fully safeguarded. EVIDENCE: Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 21 The Owner/Manager has advised the CSCI that she has recently commenced a training course leading to the Registered Managers Award. In view of the performance deficits and departures from National Minimum Standards within this service, the leadership and management approach will need to be further developed to ensure that all staff have the necessary skills and knowledge required. There will need to be adequate numbers of staff deployed and that appropriate training, supervision and the presence of suitable operational systems are safe, and support the tasks care workers are expected to undertake. This inspection concludes that none of these areas were fully reflective of National Minimum Standards. It was understood that a quality assurance and quality monitoring approach is in operation at the home. This has been inspected at previous visits and, for the most part has been assessed as not meeting the National Minimum Standard. The previous inspection indicated that the standard had not been met. Whilst this inspection was unable to access the data, the outcome of the individual National Minimum Standard indicate that the quality aspect of the care provision was in need of significant improvement and therefore the service was unable to evidence that a quality system was assuring and monitoring the care quality in an adequate and satisfactory manner. Staff supervision files were sampled. Of the 4 files seen, 1 was unsigned and undated. All files were of a ‘tick box’ design although they did contain extensive information regarding ‘bench mark’ standards. It was not possible to ascertain their relevance and use, as they did not link directly with National Minimum Standards. The content of supervision did not follow the requirements of National Minimum Standards. A number of records required by Schedule 4 of the Care Homes Regulations 2001 were inspected and found to be either incomplete or insufficient to meet regulatory requirements. Some required records were unavailable for inspection. Records needed to be improved included the Statement of Purpose, Service Users Guide, care planning documents, staffing records, duty roster and dietary records. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 22 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 1 x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 1 x 1 1 x 2 1 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 2 2 2 x x 2 2 2 Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 23 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 1 Regulation 4,5,6. Requirement The Registered Person must review and update the Statement of Purpose and Service User Guide. This is a repeat requirement. No service user should move into the home without having his/her needs assessed and being assured that these will be met. This is a repeat requirement. The Registered Person must be able to demonstarte that the home has the capacity to meet the assessed needs of service users. This is a repeat requirement. The Registered Person must ensure that service users health, personal and social care needs are set out in an individual plan of care. This is a repeat requirement. The Registered Person must promote and maintain service users health and ensure access to health care services to meet assessed needs. This is a repeat requirement. The Registered Person must ensure that service users privacy and dignity are respected at all Timescale for action 30.10.05. 2. 3 14 30.10.05. 3. 4 12, 14, 15. 30.10.05. 4. 7 15 30.10.05. 5. 8 13 30.10.05. 6. 10 13, 14, 15. 30.10.05. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 24 7. 12 13, 15 8. 14 15, 16 9. 16 22 10. 18 13, 16, 18, 19, 11. 19 16, 23 12. 21 16 13. 22 16 14. 24 16, 23 times. This is a repeat requirement. The Registered Person must ensure that service users lifestyle within the home matches their expectations, preferences, needs and aspirations. This is a repeat requirement. The Registered Person must ensure that service users are assisted to exercise choice and control over their lives. This is a repeat requirement. The Registered Person must ensure that service users and their representatives have access to a complaint procedure which includes the stages and timescales for the process, and that the complaint is dealt with promptly and effectively. This is a repeat requirement. The Registered Person must ensure that the service follows a clear procedure that will prevent service users from abuse. This is a repeat requirement. The Registered Person must ensure that service users live within a safe and well maintained environment. This is a repeat requirement. The Registered Person must ensure that service users have access to sufficient and suitable lavatories and washing facilities. This is a repeat requirement. The Registered Person must ensure that service users have access to all specialist equipment they require to maximise their independence. This is a repeat requirement. The Registered Person must ensure that service users have private accommodation which is furnished and equipped to assure 30.10.05. 30.10.05. 30.10.05. 30.10.05. 30.10.05. 30.10.05. 30.10.05. 30.10.05. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 25 15. 25 16 16. 26 16 17. 27 18 18. 19. 28 29 18, 19 19 20. 30 18 21. 31 9 22. 32 9, 10 23. 33 9, 10, 24, 26 24. 36 18 comfort. This is a repeat requirement. The Registered Person must ensure that service users live in safe comfortable surroundings. This is a repeat requirement. The Registered Person must ensure that the home is clean, pleasant and hygenic. This is a repeat requirement. The Registered Person must ensure that service users needs are met by the numbers and skill mix of staff. This is a repeat requirement. The Registered Person must ensure that service users are in safe hands at all times. The Registered Person must ensure that a thorough recruitment procedure is operated which ensures the protection of service users. This is a repeat requirement. The Registered Person must ensure that a staff training and development programme is operated in accordance with National Minimum Standards. This is a repeat requirement. The Registered Person must ensure that the home is managed in a competent manner. This is a repeat requirement. The Registered Person must ensure that service users benefit from the ethos, leadership and mangement approach of the home. This is a repeat requirement. The Registered Person must ensure that the home is run in the best interest of service users. This is a repeat requirement. The Registered Person must ensure that the staff are 30.10.05. 30.10.05. 30.10.05. 30.10.05. 30.10.05. 30.10.05. 30.10.05. 30.10.05. 30.10.05. 30.10.05. Page 26 Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 25. 37 17, 26 26. 38 23 appropriately supervised. This is a repeat requirement. The Registered Person must ensure that all records required to be held are maintained accurately and are available for inspection. This is a repeat requirement. The Registered Person must ensure the health, safety and welfare of service users and staff. This is a repeat requirement. 30.10.05. 30.10.05. 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 24 28 30 31 33 Good Practice Recommendations The Registered Person is recommended to undertake a review of the homes furniture and fittings to ensure that it is fit for purpose. The Registered Person is recommended to ensure that at least 50 of care workers are qualifed to NVQ level 2 or equivalent by December 2005. The Registered Person is recommended to ensure that adequate financial support is available to ensure that staff have access to suitable training. The Registered Person is recommended to ensure that the Manager has achived an NVQ level 4 in care and management by December 2005. The Registered Person is recommended to review the homes quality assurance approach. Brookfield I56 I05 s17783 Brookfield v245533 UI180805 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection 1st Floor Fairfax House Causton Road Colchester CO1 1RJ 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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