Inspection on 24/08/06 for Brookfield

This inspection was carried out on 24th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Brookfield 7-9 Hayes Road Clacton on Sea Essex CO15 1TX Lead Inspector Tim Thornton-Jones Key Unannounced Inspection 24th August 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brookfield DS0000017783.V310126.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.V310126.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 01255 427993 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) of places Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 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 only (not to exceed 11 persons) 30th May 2006 Date of last inspection 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 not 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. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The summary of this inspection concludes that some improvements to parts of the service have been developed although there remain key concerns around the organisation of care and the quality outcome for service users. Aspects of the assessed ratings have improved although there remain a relatively high proportion of National Minimum Standards that do not meet requirements. These include a significant proportion of unmet standards carried forward from previous inspection visits. Of the seven outcome groups reported upon within this inspection process, three were considered to be ‘poor’ and the remaining four as ‘adequate’. The overall outcome indicates that the registered person, although having made some improvement, is required to make further significant improvements to ensure that the care outcomes meet the expectations, needs and preferences of service users. Concern around the quality outcomes for this service have continued to have been raised via previous inspections and to ensure that a clear expression of these concerns are fully understood, this report has presented some matters in more detail. Inspector’s conclusions to this inspection and that of previous reviews of the service indicate that the needs, preferences and requirements of service users currently exceed the capacity of the service to provide for them in several areas. Consequently, the rate of improvement has been very slow and for the most part limited to improvements to the environment, staff recruitment and supervision and basic care planning related matters. The care outcome requirements for the majority of service users accommodated at the time of inspection were complex, some of which appear to be outside of the registration category for the service. The inspection highlighted that service methods and approaches were not always sufficiently developed or quality checked to ensure all service users receive the support required. The registered person’s approach and understanding of qualitative matters does not reflect all the required quality outcomes of the service. This is of concern, since unless this improves, it is difficult for users of the service to be reassured as to how improvements are to be achieved. The inspection concluded that the management and leadership requires improvement to provide clear evidence that the service has an adequate and reliable strategy to ensure that service users receive a fully appropriate, safe and supportive service to meet their needs and aspirations. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 6 In summarising the outcomes of this inspection the reiteration of the commitment to the service of some staff is noted and has primarily contributed to the improvements seen. There is a good level of intuitive caring apparent and the more experienced staff are worthy of praise in achieving the developments and positive elements commented upon within this report. It is acknowledged that the Registered Person and Manager successfully achieved improvements to aspects of the service that were recognised by the Commission in response to Improvement Notices recently served. The outcome for this inspection, taking into consideration the improved ratings for some National Minimum Standards, remain as poor. What the service does well: 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 DS0000017783.V310126.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.V310126.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 to 6 inclusive • Service users now benefit from information required to make an informed choice about the home. • Service users have not been fully protected from the admission procedures to ensure that the service will meet their needs. • Service users are not fully assured that their needs will be met. • Service users now have opportunity to visit the home to assess the quality, facilities and suitability of the home. • The service does not provide intermediate care services and therefore this standard was not assessed. The outcome for this sampled group of standards has been judged as ‘adequate’ based upon the information available. EVIDENCE: The case tracking approach used during this inspection identified that one service user had been admitted to the home who had, at the time of admission, a diagnosis of Dementia, a condition for which the home is not registered to provide. This person’s needs have not been adequately assessed or reviewed. The Registered Person will need to make application to the Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 9 Commission for an amendment to the current registration certificate together with supporting evidence to enable the person to remain at the home, if that is the wish of the service user and/or the home. This service outcome leads the Inspectors to conclude that the service is not able to fully evidence that service users and their representatives may not know that when they enter the home, their needs will be met. The Statement of Purpose and Service Users Guide documents produced by the home now meet with the regulatory requirement and this is a positive development since previous inspections. Whilst there have been no new admissions to the service since the last visit to the home by Inspectors, and therefore no presenting recent evidence of admission procedures, the Registered Manager was able to discuss the way in which service users thinking of entering the home would be supported. Overall the explanation provided was reflective of adequate practice and the supporting documentation, including the terms and conditions and contract, set out the information prospective service users would need. From this perspective the service meets the requirement, although a review of the homes practice will be made at the next inspection if a service user is admitted for the first time since, as earlier commented, a service user had entered the home inappropriately. Brookfield DS0000017783.V310126.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 to 11 inclusive. • Service users do not benefit from their healthcare and social care needs being set out in an individual plan of care. • Service user health care needs are not fully met. • Service users are not fully protected by the home’s policies and procedures for dealing with medicines. • Service user(s) do not always say they are respected or treated with dignity, or are observed to be. • Service users do not benefit from the homes approach to ‘end of life’ issues. The outcome for this sampled group of standards has been judged as ‘poor’ based upon the information available. EVIDENCE: The inspection identified that one service user, with a diagnosis of dementia, had been referred by the local Community Intermediate Care Team. The service user was observed periodically throughout the inspection to be seated within the lounge with no occupation and little interaction or stimulation. When spoken with by an Inspector, the service user expressed feelings of being ‘miserable and lonely’. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 11 The person was evidently hard of hearing and did not appear to have any hearing aids. An explanation was later given by staff that the hearing aids were being repaired. Expressions of isolation were further explained by the service user as a result of their impaired hearing and consequently could not hear the television or the radio. The person could no longer hold a newspaper to read. Confirmation was obtained that a close relative had visited (spouse) for 1 hour during the morning. The visitor was observed to be frail and a wheelchair user. The service user received the visitor in the dining room. Staff gave them a pot of tea and some biscuits and made them feel welcome. People entering the dining room at various times, however, did interrupt the visit and infringed upon their privacy. It was not made clear why the visit did not take place within the service users personal room. At a meeting subsequent to this inspection the registered person, Mrs Dorval, stated the visitors were given the option of using the service users bedroom but this was declined. The service user was demonstrably upset following the visit and stated to the Inspector that the spouse was very much missed. An expression of despair was made to the Inspector in that the person felt they “wanted to die”. Staff were not observed to speak or interact with the person during the frequent periods of observation during the inspection (09.00 – 19.00hrs), except for when he was supported to leave his seat and go into the dining room for lunch. At a meeting with inspectors following this inspection, Mrs Dorval stated that care staff had taken the service user to the toilet and to exercise but this had not been observed by inspectors. It was expressed to the Inspector that since admission to Brookfield his mobility and strength had decreased. The plan of care did not reflect the expression of emotional, cognitive, physical or mental health needs. Matters associated with the person’s strengths, wishes, likes and dislikes were also not identified within the plan and therefore care staff thus rely heavily upon intuitive care support giving rather than a clear, agreed, risk assessed strategy of care. This aspect of the homes performance continues to be of concern. The inspector was told by the service user that the same meal was served every day for lunch and sandwiches every night. The records were checked and it was found that a record of food consumed was being maintained within the case file. This confirmed the service user had received fishcakes or fish fingers, peas and mashed potato as stated. The care plan did not provide any reason or understanding of why the similarity of meal had been served although the manager stated that the service user had requested it. Toward the end of Inspection, Mrs Dorval implied to inspectors not to take a lot of notice of this resident as such claims of concern were frequent and that the person ‘said things’. The care plan made no reference to this area of behaviour or need relating to the individual. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 12 Mrs Dorval was asked why the person had been admitted since the home was not registered to accommodated people who have dementia. Mrs Dorval replied that she did not know the person had dementia. The Inspector advised Mrs Dorval that a diagnosis of dementia was, in fact, recorded on the Care Management pre admission documentation. At a meeting subsequent to this inspection, Mrs Dorval confirmed that the pre-inspection assessment provided by the local authority to the home was incorrect in specifying that the service user had a dementia. She stated that the service user’s health consultant had confirmed this in writing to the home. As part of the case tracking approach, four service user files were examined. The sampled plans of care had not significantly improved in terms of their ability to inform service users and carers of personal, emotional, recreational or healthcare related practices. The quality of recorded information and care planning process had, in parts, deteriorated since the last inspection. The decision making process appears to be now based upon assessment of risk soley rather than as a person centred care planning process, with methodology and clear achievable objectives. There remains a lack of evidenced consultation with service users. The approach adopted by the home remains reflective of a ‘medical model’, a matter that has been of concern previously and has been reported within previous inspection reports. The documents continue to have little indication of a ‘person centred’ approach to planning. The care management system was not adequately developed to enable, for example, a new member of staff, of whom there are two, to be sufficiently confident to deliver safe and appropriate care; including guidance to provide care in the least intrusive and most supportive and consistent manner, observing dignity and self-respect. There was some evidence that staff were, in practice, doing their best to achieve this although almost entirely generated from an intuitive perspective. Service user ‘needs’ written within the plan were identified as ‘risks’ or ‘hazards’ and did not provide an adequate basis for the care or support to be delivered appropriately. Carers, when spoken with were unable to fully demonstrate their understanding of a care plan or how they are used to support a persons needs. The service continues to be rather ‘form’ led, which tends to deflect carers from considering or evaluating presenting needs and support requirements of service users. The completion of the forms presented as somewhat routine rather than used as an ongoing tool to improve care outcomes. A continence risk assessment within one plan seen, was the first indication that a service user had an Iliostomy. (a surgical procedure that allows collection of urine into a special bag from an opening in the abdomen). This Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 13 was not reflected in the care plan for the person. There were no details as to how the care was managed in this instance, how much support the individual required or professional guidance to be followed. Risks and hazards identified were brief and provided further example of a limited understanding of the need for utilising appropriate risk assessments within care practice, for example one heading - ‘contracting the common cold’ was identified as a risk, the reduction of the risk was ‘to have a flu jab’. A flu vaccination is not generally considered to be prevention from the common cold. There was no evidence available that permission had been sought for the vaccination or consultation with the service user. A further example seen identified ‘choking’ as a risk, leading a decision to be made for the individual to have soft food. Within the same file it was positive to see that a nutritional risk assessment was in place, which informed the plan to state that the individual had no difficulties in swallowing or chewing; an outcome that contradicts the need, and subsequent decision, for soft food. The assessments did not include the use of dentures or the condition of the persons’ mouth or teeth or any health or physical problems. Daily reports referred to codes, the codes referred to headings and the headings did not correspond to individual assessed needs and care planning arrangements. The pathway to the process was therefore not fully understood. All the files examined indicated that service users had continence management requirements and were provided with continence management products. There was no evidence of continence promotion, assessment or care management and associated risks and preventative care or guidance from Continence Advisors. The pressure sore risk assessment tool being used was not a version used in current practice or was particularly suitable for use in care homes to enable useful information to be obtained to form part of a proactive strategy in the prevention, detection or management of risks identified. No evidence was recorded of assessment carried out by District Nurses or intervention for the reduction in pressure sores. This is a matter that Mrs Dorval, the Manager, had been advised about by healthcare professionals during recent heath reviews undertaken by Tendring Primary Care Trust (PCT). Current person centred practice guidance such as provided by the National Institute for Clinical Excellence (NICE) 2005 for the detection and prevention of pressure ulcers were not being followed. Service users were observed to remain seated for extended periods throughout the inspection. One service user with continence needs was observed to be seated for the duration of the inspection (some nine hours) and remained seated in the lounge to eat lunch from a tray. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 14 There was no evidence of psychological health monitoring, preventative or restorative care. Those service users with more specific or complex needs, frail and poorly were only observed to receive attention with basic needs. There were no observed opportunities for appropriate exercise or activity to promote mobility and no appropriate interventions documented for those identified as ‘at risk’ evident. Monthly evaluation records had been commenced it would appear as part of a review process, which is positive. Changes in needs relating to confusion, falling and loss of appetite were recorded on the monthly evaluation for one service user and associated GP visits including findings and treatment. There was no evidence of care planning or monitoring arrangements for this individual, particularly around eating and drinking, confusion or risk of falling. A risk was identified for the person falling at night due to confusion. To reduce the risk the plan stated that care staff were to ensure night sedation was given. There was no evidence of referral for this person to the Falls Risk Programme and nutritional records had not been completed for 5 days, even though food intake was a stated concern, prompting a referral to the GP. Incident records were inspected with one incident having been recorded. This did not correspond with the individual incident record. One Regulation 37 notification to the Commission was provided which related to the incident but the manager was unable to provide copies of any other Regulation 37 of previous incidents relating to service users in the home. Medication administration records were examined and found to be, in part, inaccurate and incomplete. The inspector concluded that no records held of medications leaving the home or disposed of were available. At a meeting subsequent to this inspection Mrs Dorval stated to inspectors that the medicine returns book was, in fact, up to date and available for inspection. A bottle of unused medication was found in the Controlled Drugs box. One medication record had two prescriptions for the same drug, each with a different dose. One of the prescriptions had been discontinued but not removed from the administration records. Another prescription administration record was for the previous month and carried over, the prescription profile had been hand written by staff and was not complete. The records for medication prescribed for ‘as and when required’ were blank and did not give any indication using the codes provided as to whether the medication was offered and refused or not required. The record for another service user was dated for the previous month. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 15 Although the medication for another service user had been discontinued on the 19th of the month the administration records were blank as from the 9th of the month except for one medication, again no codes were inserted to identify why the other medications were not given. This practice concludes that the homes medication policy and procedure was not followed. None of the documentation sampled gave a clear indication that the service user was integral to the decision making and monitoring process. This approach contributes to a lack of dignity and empowerment for those receiving the service. Issues around mental capacity had not been assessed or considered, particularly with regard to promoting strengths, stimulation and well-being. Some staff demonstrated via observation good practice relating to speaking with a tone of respect and understanding using appropriate language. The senior carer expressed appropriate concern for service users well being by advising them, for example, to expect loud noises during the afternoon from the air show display over Clacton. On other occasions staff were heard/observed to speak abruptly, continue own conversations and to respond to their mobile phones at work. Care documentation did not provide evidence of individual consultation or planned arrangements for illness and/or ‘end of life’ choices or preferences to inform care staff how the individual wished to be treated. The homes policy did not reflect this process or the rights of the individual and therefore requires review. The outcomes for this group of standards continue to be of concern following a comprehensive review of practice. Individual Senior Carers are able to demonstrate a positive understanding of good care management principles via the observed interface between them and some service users, although the strategic method of delivering appropriate, informed and safe care is not fully achieved. The service, in the opinion of the Inspector, has not demonstrated full professional capacity to meet all the known and assessed needs of service users. Services within the home for people with sensory or cognitive impairment or mobility needs were not demonstrably based on current good practice, although it is acknowledged that carers attempt to provide for them. The key working system, purported to be in operation did not evidence that service users benefit from an individualised approach. No training has been provided for care staff undertaking this role. Staff collectively, as a group, did not demonstrate that they have the skills, knowledge and experience to meet the assessed needs of service users, although it is acknowledged that some senior carers do have underpinning knowledge and skills. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 16 In the opinion of the Inspector the care arrangements are not adequately comprehensive and lack an attention to detail. Care staff do provide intuitive care and those who have received training provide a service on an informed basis although not in accordance with a strategic and co-ordinated plan. The practice lacks leadership and management to ensure that residents receive a safe, appropriate and informed service. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 to 18 inclusive. • Service users do fully not benefit from any of the above care outcomes. The outcome for this sampled group of standards has been judged as ‘poor’ based upon the information available. EVIDENCE: From the commencement of the inspection at 09.00 am all service users were observed to be seated in the lounge and most were ‘dosing’. They were awoken by staff at 10.00am to be provided with a hot drink and toast. One service user told the Inspector that they were got up at 06.00am. It remains unclear why service users are woken and assisted to get up so early as 06.00am. There are no details within the sampled records to explain this. When asked if the toast was service users breakfast, the carer advised inspectors it was a mid morning snack and that the service users received their breakfast earlier when they got up, either in their room or in the dining room. A local radio station was playing for part of the morning – the music was of a contemporary nature and thought by inspectors as possibly not altogether appropriate for the age group of service users and it was unclear as to whose benefit it was playing. The radio was later turned off and the television put on. Service users were not consulted about either of these actions and no Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 18 service user was observed to be actively involved. One service user, as previously mentioned did not have prescribed hearing aids and said he could not hear anything, it was later advised that they had been sent away for repair. No alternative arrangements were in place to enable the service user to hear. The home does not have a loop system in place. Some limited and interaction was observed throughout the day between staff and those service users more able to verbally respond. Inspectors concluded that some development is required to explore various approaches to appropriately engage people in maintaining and stimulating social and recreational interests, linked to individual needs and preferences. Staff do not demonstrate the skills and detailed knowledge required to understand the needs and therapeutic approaches to care and support for people with varying levels of cognitive impairment and mental health needs. This training need was demonstrated by the limited interaction observed during the inspection. The service users were observed to have varying cognitive and communication ranges; ranging from substantial difficulties in word finding, ability to make choices and fine movement, to reasonable cognitive abilities but troubled with limited memory for events, conversation and people. These needs present carers with real challenges to provide an appropriate level of service and point toward a training and development need. The Manager must review current service users to ascertain whether the home is able to provide a service to residents with presenting complex care needs in terms of the present registration category. One care file indicated that one individual required glasses for reading, although mostly did not use them. The person was given a newspaper by a carer, although was not offered his glasses and nobody offered to read the newspaper to the person. The person was observed to flick through the paper and took it apart as it emerged the interest was for the advertising flyers contained within it. After approximately 10 minutes the manager took the paper from the person without an explanation and the paper was replaced by a pack of cards. The service user then went to sleep. The pack of cards remained on his table for the remainder of the inspection. During the afternoon a care worker was observed to try and engage a service user, who had presenting mental health needs, to participate in completing a jigsaw puzzle. This was a positive and engaging action. The puzzle was brightly coloured and the pieces very small. The service user was unable to perceive the picture of the puzzle or focus on it and was unable to pick up the pieces having a clearly very limited attention span. The activity was shortly abandoned and the service user resolved to wander around the home and appeared agitated. The staff continued to chat amongst themselves. These examples were detailed to provide an overview of the challenges that carers have in providing appropriate social and emotional stimulation for the group of service users, some of whom have complex care needs. The Manager Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 19 will need to ensure that service users interests in these areas are accurately assessed, are subject to consultation and be properly planned for, together with improvement to assist staff in encouraging appropriate and motivating activities. It is clear that staff are attempting to provide various activities, and this is encouraging, although may not always be appropriate. One file examined stated that the individual liked to go out to the town and this was identified as a ‘risk’. There were no care planning arrangements for enabling and supporting community access for the individual. The Manager must ensure that risk assessments are in place to enable a person to participate in an activity rather than as a reason why they cannot. There were no restrictions relating to visiting. A service user was observed to receive a visit from his spouse during the morning. Brookfield is limited on facilities for service users to receive visitors in private and as such the service user received the visitor in the dining room as previously stated. This was not ideal as privacy was demonstrably a problem. The main meal for the day of the inspection was meat pie, vegetables and potatoes with ice cream for desert. This did not correspond with the menu for the day. The home had continued to operate the same two weekly running menus as seen on the last inspection. The senior carer indicated that a choice of meals was offered daily. Food stocks were inspected and were considered insufficient to provide service users with a healthy, balanced and nutritious diet. The small domestic freezer in the kitchen contained fish fingers, frozen vegetables and a small meat pie, considered by the Inspector to be probably sufficient enough for one meal. The senior carer mainly prepared and cooked the main meals. When the senior carer was asked if there was any other food stocks she replied that the freezer upstairs was empty and the home was awaiting a food delivery. Food served to one individual was observed to have been blended together. Staff advised that this was to avoid lumps, as the service user would stop eating if there were lumps in the food. When the senior carer was advised that the items of food could be liquidised separately to ensure separate flavours and maximise the experience for the service user, she indicated that it was not possible to liquidise some food items sufficiently to avoid lumps. Care planning arrangements did not reflect the individual’s food choices or identify difficulties in eating. The advise of a dietician, or similar, in this instance had not been sought. Staff will need further training and development in order to provide an appropriate response to care planning in this area. Whilst some staff were observed to show considerate and reflective intervention, other carers clearly Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 20 did not have appropriate knowledge understanding or skills to adequately respond and an apparent lack of specific supervision. Inspectors concluded that service users were not receiving an appropriate service based upon the inspection findings in this care outcome group. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 21 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17. • Service users do not benefit from a clear, simple and accessible complaint procedure. • Service users are not fully protected from the homes safeguarding adults procedures. The outcome for this sampled group of standards has been judged as ‘adequate’ based upon the information available. EVIDENCE: The home has a complaint register to log all complaints received. This states that complaints are to be responded to within 7 days. The complaint procedure, a different document states that complaints are to be acknowledged within 72 hours and responded to within 21 days. The procedure within the Statement of Purpose does not include details of how to contact the Commission. The complaint procedure directs the complainant to the home manager but does not advise how a complaint should be made concerning the manager, or to make a complaint in the absence of the manager. The complaint procedure within the service users guide is more comprehensive and informative than the individual procedures seen. The confusion around these procedures continues to be problematic in that these matters have been raised previously and have not been resolved. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 22 Arrangements for safeguarding adults have developed in that the home has taken delivery of the policies of the local authority. The home, however, must ensure that their policy appropriately links with the local authority version since the local authority is the lead agency for safeguarding adult procedures and referrals. Since the previous inspection the local authority, in relation to alleged institutional abuse, concluded the matter referred to in the previous inspection report. The outcome concluded that of inadequate evidence to uphold. The local authority has lifted the temporary prevention of service users being admitted to the home whilst the investigation was ongoing. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 23 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24 & 25 • Service users are not yet reassured that the environment is safe. • Service users do not fully benefit from a comfortable outdoor communal facility. • Service users benefit from equipment they require to maximise independence. • Service users benefit from adequately decorated and furnished bedrooms. • Service users do not yet benefit from the knowledge that they live in a safe home, although is comfortable and clean. The outcome for this sampled group of standards has been judged as ‘adequate’ based upon the information available. EVIDENCE: The location of home is good and in close in proximity to community resources. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 24 A tour of the building was undertaken including all communal areas and bedrooms. No odours were found. Bedrooms visited were found to be clean and adequately decorated. There were no obvious safety hazards noted. One en-suite had a WC seat that was ill fitting and needs to be improved. Some improvement to the décor was stated by the manager is part of ongoing routine maintenance. The rooms were domestic in character and homely in appearance although some further areas to decoration are required. Furniture and fittings were adequate although the manager will need to ensure that these are kept under review. Some additional equipment had been purchased, including a sit-on weigh scale and new bedside tables. Whilst the manger has not formally arranged for the premises to be assessed by a suitably qualified (in older peoples related services) person, the physical environment has been adapted as far as possible to assist people with mobility difficulties. For example, steps have been removed in favour of ramps and grab handles were in place. The manager must ensure that all toilet and bathing areas are assessed to ensure that all aids and adaptations are fitted where identified as required. One such area was noted to not have a toilet tissue holder fitted. The Manager should ensure that an assessment of the premises includes consideration of door widths since one service user (now not resident at the home) had difficulty negotiating doorways with a wheelchair. The home has a number of vacancies and a comprehensive assessment will need to be undertaken if the home considers an application from a wheelchair user. (See recommendation) All current service users are accommodated in single rooms, most of which have en-suite facilities. All rooms are centrally heated and were warm on the day of inspection. Radiators have guards fitted. Emergency lighting is fitted throughout the home. The small rear courtyard garden is enclosed although it was noted that the washing line is located diagonally across the seating area. The manager will need to review the arrangement to ensure that service users are able to use this area. The dining room is in need of redecoration in that a large patch of wall is a different colour to the remainder, appearing that the room had been painted around a piece of furniture that had since been removed. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 25 A passenger lift operates between ground and first floor to enable access to all rooms. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 to • • • • 30 inclusive. Service users Service users Service users Service users do not benefit from assessed staff numbers or skill mix. are not assured that they are in safe hands at all times. benefit from the home recruitment procedures. do not fully benefit from staff that are in need of training. The outcome for this sampled group of standards has been judged as ‘adequate’ based upon the information available. EVIDENCE: Staff roster shows that on the day of inspection, including the Manager, three staff on duty between 8am and 11am. For the remainder of the day between 7.45 and 8pm, two staff were on duty to provide personal care. Cooking hours are provided between 11am and 1pm and 5pm to 6pm. Carers who are already working at the home undertake these duties. The manager must address the matter of cross infection risk. One senior staff was observed to diligently wash hands and take precautions every time the kitchen was entered reflecting good practice. This was in contrast to other carers who were less diligent in this regard. The manager should make the home policy and practice procedure clear to all employees. The staff/service user ratio was last calculated, as specified by the manager, on 4th March 2006 using the residential forum calculation method (as recommended by the Department of Health). The ratio calculation was used on the basis of nine service users being resident. The current occupancy is below this level and therefore the ratio was in need of updating to reflect the Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 27 present position. Ratios must be reassessed when service user numbers or dependency level change to ensure there are sufficient numbers and skill mix of staff. Staff deployment was confirmed as being 245hrs per week. There is no method currently to demonstrate that these levels are adequate to meet the known needs of service users. Staff records were examined to ensure that all regulatory requirements were being maintained. Three files were assessed at random. For one established carer the recruitment records were satisfactory. A staff supervisory contract was evident and supervisions were on track to meet the six sessions per year stated within National Minimum Standards. This member of staff has an NVQ qualification at level two and is currently working toward a level three award, which is positive. A second carer file recruited in June 2006 was sampled. Recruitment information and checks were satisfactory. An induction format commenced at the time of employment. A supervision contract was in place although this was unsigned. A third carer file was examined and the record indicated the person had commenced employment in August 2006. The references were both ‘to whom it may concern’ and from a personal source rather than from a previous employer. The Manager is advised to make further enquiries since the evidence available for reference purposes were not adequate. Other recruitment information was satisfactory. Cleaning staff are employed. All staff members are required by the manager to read policies and practice procedures and following this, sign a ‘competency register’ to acknowledge they understand the requirements. Where appropriate, care staff sign to acknowledge they have received instruction and they understand the requirement of the policy and/or procedure in question. The home maintains a staff training register, which details the name of the staff member, the type of training undertaken, the date the training took place etc. This is a developing area although no training and development activity was evident to show how existing training and experience is used in relation to the job description to identify training and development needs or to plan how future training needs are to be met. On this basis the home was not able to fully demonstrate that all staff form an appropriate skill and knowledge mix. Staff interviews for two cares were undertaken. This indicated a training need in various areas including care planning and associated skills such as recording Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 28 and assessment skills. manager. Staff stated they felt adequately supported by the Whilst the training records available indicated that some staff had attained NVQ2 this does not currently amount to the 50 of staff employed to provide personal care as stated within National Minimum Standards. The senior carer was able to demonstrate underpinning knowledge and understanding of safe care delivery. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 29 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 to 38 inclusive. • Service users are not fully assured that the management of the home is able to discharge their responsibilities fully • Service users do not fully benefit from the ethos, leadership and management of the home. • Service users do not benefit from the home quality assurance and quality monitoring approach. • Service users benefit from the staff supervisory system. • Service users are not fully safeguarded by the homes record keeping, policies and procedures. • Service users health and safety are not fully promoted and protected. The outcome for this sampled group of standards has been judged as ‘adequate’ based upon the information available. EVIDENCE: Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 30 The registered manager, Mrs Dorval, has advised CSCI that she is working toward a qualification leading to NVQ level 4 in Care and Management. No job description was available regarding the role and structure of the registered manager and it was therefore difficult to make clear comparisons between the managers stated and actual role. It was found that several of the care inspected management documentation had been written and signed by senior care staff. When inspectors requested an explanation of the care management arrangements, the manager directed the inspector to the senior on duty and did not take full part in the process. Information available at the home indicated that the manager had not been fully integral to the training associated with the revised documentation. This is of some concern and supports the view that a disproportionate amount of management related tasks might be delegated inappropriately. The manager was requested by Inspectors to be interviewed without the senior staff present to ascertain the level of both involvement and understanding of the presenting care management system. This concluded that the manager had obtained the assistance of an external agent to help with the development of areas of the service delivery. Of the various areas of development that were viewed, these were partially responding to the development needs of the home, but not all. There was no evidence that staff, service users and other stakeholders follow, or contribute to, an open and clear strategy that influences the way that care is delivered. The inspection concluded that the Manager was not able to fully demonstrate a sound leadership approach to drive improvements. The homes approach to quality assurance remains broadly unchanged since the previous two inspections. The Manager provided a summary of quality statement covering the period December 05 to April 06. This document upon inspection did not provide a basis for evaluating the quality of the service or was a summary of the data collected. There was no quality based approach to developing areas of identified shortfall toward National Minimum Standards or regulatory shortfalls. The document made a number of claims with regard to the homes quality operation and outcomes that the inspection was not able to evidence. The registered person and manager must address the quality and monitoring within this service to address the repeated short falls. No accounting or financial information was available other than confirmation of the minimum and maximum fees charged. No other charges are stated to be levied although service users are expected to fund services such as chiropody and other non-primary healthcare services provided free of charge. Personal items and services such as newspapers and hairdressing are not included within the weekly fees. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 31 The manager advised that no cash was being held in safe custody on behalf of service users. The manager’s involvement in staff supervisions were reviewed on the basis that hand written notes made at the time of supervision did not match the signature of the manager entered on the supervision record sheet. Mrs Dorval was asked about this and confirmed that a consultant had been present during the supervisory process and had written the notes. Mrs Dorval, who was stated to have also been present at the supervision, signed the document. On this basis there is some concern regarding confidentiality issues as no evidence was presented as to any consent by the interviewee to have an external person present at the supervisory session. The staff member in question was interviewed by an inspector and asked about the sessions. The carer was rather vague and unclear about the circumstances of the supervision and stated there was ‘several people around’ and was unable to clearly explain the circumstances of the supervisory session or the outcomes. It seems clear that the practice around the role and function of supervision requires review, since employees are evidently unclear about their role in the process and the manager is unclear about supervisory best practice. The manager would benefit from attending suitable training on how to manage the supervisory process as a whole. The way in which the session was recorded, with the exception of matters already expressed, were satisfactory. Various records were examined as follows: Accident book. The book seen was blank although data held in care plans sampled indicated that a service user had two falls both of which resulted in injury. Therefore the accidents were not adequately recorded and responded to. Records of reportable occurrences were not available. The Statement of Purpose and Service user Guide has been revised and now comply with requirements. The Manager is advised to ensure that all previous copies and versions are removed and/or taken out of circulation as far as practicable as some earlier versions of the documents were viewed. Missing Persons procedure met with requirements. The staff roster was examined and found to be adequate. The record of food served is maintained individually in each service users records. This overall approach is reflective of good practice, however, whilst sampling these records it was found that the design and layout of the record Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 32 was good and provided opportunity to comment on the type and quality of food consumed, but some had not been completed. Fire alarm and emergency lighting record commenced July 06 and was being maintained. Fire self assessment completed on 10/3/05 has not been adequately completed and requires updating. A health and safety policy was seen dated 2005. Aspects of this policy were not being followed, for example one carer was observed to not wash their hands every time they entered the kitchen. This was discussed with the staff member who stated they did wash their hands on one occasion but accepted not all. Advice was given regarding the risk of cross contamination when carers enter the kitchen having undertaken care related tasks. The Inspector did have concern arising from the challenge of a carer who expressed resistance to the requirements explained in adhering to anti-cross contamination procedures suggested. One senior carer was noted to do act appropriately, reflecting both the homes own policy and good practice. One staff member was observed to undertake a manual handling procedure in a potentially harmful way. The staff member was recently recruited and had not previously benefited from training in safe moving and handling techniques. The manager must ensure that staff who have not received either food hygiene or moving and handling training, for example, do not undertake tasks related to these areas without appropriate supervision. The overall Health and safety document was, overall, informative and a useful guide for staff with the exception of the guide on blood pressure matters at the rear of the document, which is not appropriate and is recommended to be removed. The service did not have financial records available for inspection. Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 33 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 3 3 2 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 1 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 1 18 1 2 X 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 1 N/A 3 2 2 Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 34 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 OP3 Regulation 14 Timescale for action No service user should move into 31/10/06 the home without having his/her needs assessed and being assured that these will be met. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. The Registered Person must be 31/10/06 able to demonstrate that the home has the capacity to meet the assessed needs of service users. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. The Registered Person must 31/10/06 ensure that service users’ health, personal and social care needs are set out in an individual plan of care. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. The Registered Person must 31/10/06 promote and maintain service users health and ensure access DS0000017783.V310126.R01.S.doc Version 5.2 Page 35 Requirement 2 OP4 12,14,15 3 OP7 15 4 OP8 13 Brookfield to health care services to meet assessed needs. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. 5 OP9 The Registered Person must 31/10/06 ensure that the procedures for the receipt, storage, recording handling and administration of medicines are adhered to within a risk management framework. 13, 14, 15 The Registered Person must 31/10/06 ensure that service users’ dignity is respected at all times. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. 12 The Registered Person must 31/10/06 ensure that the home has robust procedures to support service users who are ill or are in need of care toward the end of their life. The Registered Person must 31/10/06 ensure that service users’ lifestyle within the home matches their expectations, preferences, needs and aspirations. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. The Registered Person must 31/10/06 ensure that visitors are enabled to spend time with their friends or relatives in private and undisturbed. The Registered Person must 31/10/06 ensure that service users are assisted to exercise choice and control over their lives. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. DS0000017783.V310126.R01.S.doc Version 5.2 Page 36 13(2) 6 OP10 7 OP11 8 OP12 13, 15 9 OP13 12(4)(a) 10 OP14 15, 16 Brookfield 11 OP15 17(2)(i) 12 OP16 22 The Registered Person must 31/10/06 ensure that service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Registered Person must 31/10/06 ensure that service users and their representatives have access to a complaints procedure that includes the stages and timescales for the process, and that the complaint is dealt with promptly and effectively. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. The Registered Person must 31/10/06 ensure that the service follows a clear procedure that will prevent service users from abuse. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. The Registered Person must 31/10/06 ensure that the home meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. The Registered Person must 31/10/06 ensure that the numbers and skill mix of staff meets service users’ needs. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. The Registered Person must 31/10/06 ensure that service users are in safe hands at all times. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. The Registered Person must 31/10/06 Version 5.2 Page 37 13 OP18 13,16,18, 19 14 OP19 23(2)(d) (i)(o) 15 OP27 18 16 OP28 18, 19 17 Brookfield OP30 18 DS0000017783.V310126.R01.S.doc ensure that a staff training and development programme is operated in accordance with National Minimum Standards. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. 18 OP31 9 The Registered Person must 31/10/06 ensure that the home is managed in a competent manner. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. The Registered Person must 31/10/06 ensure that service users benefit from the ethos, leadership and management approach of the home. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. The Registered Person must 31/10/06 ensure that the home is run in the best interest of service users. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. The Registered Person must 31/10/06 ensure that the financial and accounting plan for the service is open to inspection and reviewed annually. The Registered Person must 31/10/06 ensure that all records required to be kept are maintained accurately and are available for inspection. This is a repeat requirement. Previous action date was 10/02/06 and 30/06/06. DS0000017783.V310126.R01.S.doc Version 5.2 Page 38 19 OP32 9, 10 20 OP33 9,10, 24, 26 21 OP34 25(3)(a) (b) 22 OP37 17, 26 Brookfield 23 OP38 13(5) The Registered Person must 31/10/06 ensure that staff undertake procedures that do not place service users at risk of harm. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP24 Good Practice Recommendations It is recommended the Registered Person undertake regular reviews of the home’s furniture and fittings to ensure that it is fit for purpose. The Registered Person is recommended to ensure that prior to any admission of service users who rely upon wheel chairs, that the premises are assessed to ensure that such persons can be safely and appropriately accommodated The Registered Person is recommended to review all service users to ensure they have their legal rights protected, including access to advocacy services. 2. OP19 3. OP17 Brookfield DS0000017783.V310126.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex 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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