Inspection on 03/11/05 for Brookfield

This inspection was carried out on 3rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Brookfield 01/08/07

Brookfield 16/10/05

Brookfield 16/05/05

Brookfield 23/11/04

Brookfield 15/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Brookfield 1 Clayhall Road Alverstoke Gosport Hampshire PO12 2BY Lead Inspector Annie Billings Unannounced Inspection 3rd November 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 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 DS0000011753.V261836.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brookfield Address 1 Clayhall Road Alverstoke Gosport Hampshire PO12 2BY 023 9258 1103 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) j.a.filsall@tinyworld.co.uk Mrs J A Filsell Mrs J A Filsell Care Home 29 Category(ies) of Dementia - over 65 years of age (29), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (29), Old age, not falling within any other category (29) Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2005 Brief Description of the Service: Brookfield is a twenty-nine bedded home, set in attractive grounds in a residential area with local amenities close by, with pleasant views of Stoke Lake. The home has been extended over the years to provide accommodation for twenty-nine older people, including those with dementia or mental health problem. Accommodation is arranged over three floors, with a passenger lift providing access between floors. Communal areas include a large comfortable lounge, pleasant dining room and two smaller conservatory lounges. Two communal assisted bathrooms are available, and many rooms benefit from an en-suite WC. The home is well screened from the road, and the grounds provide additional seating areas, including a sensory garden, recently developed. Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4 hours and was the second inspection of the year April 2005 to March 2006. Many of the core standards were inspected during the previous visit on the 16th May 2005; therefore referral to both reports will give a full overview of the service. A partial tour of the premises took place and care and other records were inspected. Discussions were held with nine of the residents, two visiting relatives, three staff and the registered manager / provider Mrs Filsell. The care manager was also present for most of the inspection. Comment cards were received from two residents and seven relatives, with additional information supplied within a pre-inspection questionnaire. What the service does well: What has improved since the last inspection? In addition to the existing extensive programme of activities, the home has recruited an activities co-ordinator, who has recently completed training by Age Concern, to ensure the appropriateness of activities. Since the last inspection the programme of decoration has continued in the lounge, hall and stairwell, in addition to refurbishment of four bedrooms, and replacement of areas of worn carpeting. Shower rooms have also been refurbished. Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 6 Boiler room doors have been fitted with locks, to ensure the safety of residents. 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 DS0000011753.V261836.R01.S.doc Version 5.0 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 DS0000011753.V261836.R01.S.doc Version 5.0 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): These standards were not inspected. EVIDENCE: Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected. EVIDENCE: Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 10 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, 14 An extensive programme of activities and recreation provides residents with variety and choice, based on their interests and needs. Residents enjoy a comfortable lifestyle, which promotes independence and a good quality of life. EVIDENCE: A number of residents spoken with described a wide range of activities including ball games, board games, puzzles, reminiscence, skittles, sing-along, arts and crafts, music with movement, and manicures. One resident advised “there is always something to do”. The Alzheimer’s Society currently organise activities within the home, with staff organising additional events and activities in the home. Photographs of recent events were displayed in the corridors, and evidence of a recent Halloween party was still in place. In addition to an already extensive programme of activities provided by an occupational activities service and volunteers who provide further craft, reminiscence and reading sessions, an activities organiser has recently been recruitment and trained through Age Concern, to further extend the programme. Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 11 Social events are held on a regular basis, and invitations are extended to relatives and friends to participate. Evidence of a recent Halloween celebration was seen in the home, with residents being involved in making decorations. Photographs of the event were displayed in the home. The manager was also heard discussed a fireworks display planned for the weekend. Local clergy visit the home monthly, and a service was underway during the visit, to meet the religious needs of residents and arrangements were made with the minister to discuss plans for a Christmas carol service. Flexible routines were observed, with residents chatting in the conservatory, meeting with relatives in quiet areas, participating in a religious service, playing cards or sitting in their rooms. Residents advised they could choose to join in the programme of activities, and were encouraged to join the exercise classes. One resident said, “We do as we please, there are no limitations”, and one visitor commented that their relative was very well cared for and treated very much as an individual. Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected. EVIDENCE: Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Residents live in clean, safe, comfortable and well-maintained surroundings. EVIDENCE: Brookfield is situated in a residential area of Alverstoke, with several areas of the home enjoying views across Stokes Bay. The home was decorated throughout in 2004, and has a continual programme of redecoration and refurbishment. Since the last inspection the lounge, stairwell and four bedrooms have been redecorated, areas of worn carpeting replaced, and locks placed on boiler room doors to ensure the safety of residents. Shower rooms have also been refurbished. Minor issues of maintenance had already been identified, and were being addressed. Communal areas include a large comfortable lounge, pleasant dining room and two conservatory lounges, all of which were comfortably furnished. A screen has been purchased, and was due to fitted in the lounge on the day of the visit, to provide film shows for the residents. Communal bathrooms and WC’s Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 14 are sufficient to meet the needs of residents, and many bedrooms benefit from an en-suite WC. Residents spoken with confirmed their satisfaction with their rooms, saying, “I am very comfortable and have everything I need”, and another described the home as “very friendly and comfortable”. A sensory garden with additional seating and water feature has been established, with further lawned areas, some overlooking the Lake. All areas of the home were cleaned to a good standard, including the laundry, which although small, was well organised, efficient and hygienic. One relative commented that the home is “very clean and tidy”. Infection control notices were displayed and appropriate sluicing and hand washing facilities are available. Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 15 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): 29 Shortfalls in some recruitment records do not demonstrate the homes robust recruitment procedures. EVIDENCE: Residents and relatives spoke warmly about the staff team and the support they receive. Some of the comments received included, “ Staff are excellent”, “Staff are so good, friendly and helpful” and “They’re excellent, couldn’t do better”. Three staff files were sampled, two of which contained appropriate documents to confirm that appropriate checks were undertaken prior to recruitment of staff, although no interview notes were available. One member of staff recently employed had no photograph or proof of identity on file. Issues were identified within both references received, but without interview notes, there was no evidence that these had been addressed with the applicant. This was discussed with the provider, who agreed to maintain interview records and proof of identity within recruitment files, and explained that they had recently acted upon advise from an outside source that these were no longer required. Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 16 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): 35, 38 The home is well run, records are maintained to a high standard and effective procedures are in place to ensure the health, safety and welfare of residents, and that their financial interests are safeguarded. EVIDENCE: All residents’ finances are supported by their families or advocates without the involvement of the home. Personal allowances are held for safekeeping. Three records were checked and found to be accurate and well maintained. The fire logbook evidenced that maintenance and internal testing was undertaken at appropriate intervals, with staff receiving fire safety training twice yearly. A fire risk assessment is reviewed on a monthly basis. Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 17 Maintenance certificates of equipment used in the home are all current, and health and safety risk assessments for the premises and all areas of working practice are reviewed on a regular basis. Accident reports sampled were detailed, and a system in place to audit and monitor falls. The home has recently taken part in a risk management audit undertaken by the Osteoporosis Society. Environmental Health visited the home in August 2005. Three issues were identified; one of which has been addressed and evidence was available to confirm the other is being addressed. The third issue relates to the providers plan for kitchen alterations, but these are still in the planning stage. Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 19 NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Extracts may not be used or reproduced without the express permission of CSCI Brookfield DS0000011753.V261836.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!