Inspection on 07/11/05 for Brookfield

This inspection was carried out on 7th 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 28/07/06

Brookfield 15/03/06

Brookfield 27/02/05

Brookfield 16/09/04

Brookfield 29/03/04

Brookfield 01/10/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Brookfield 71 Crofts Bank Road Urmston Manchester M41 0UB Lead Inspector Elizabeth Holt Unannounced Inspection 7th November 2005 09:15 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 DS0000006700.V262724.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 DS0000006700.V262724.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brookfield Address 71 Crofts Bank Road Urmston Manchester M41 0UB 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) 0161 747 5365 0161 748 2626 Mrs M.J. Chell Mrs Catherine Ann Shea Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Brookfield DS0000006700.V262724.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users shall be 21, all of whom require nursing care. Registration is subject to compliance with the minimum staffing levels indicated in the Notice served in accordance Section 25(3) of the Registered Homes Act 1984 on 20 October 1999. 27th February 2005 Date of last inspection Brief Description of the Service: Brookfield Nursing Home is registered to provide accommodation for up to twenty-one residents requiring nursing care. The responsible individual is Mrs M.J.Chell. The home is located in a residential area of Urmston and is within easy walking distance of local shops, market and public transport facilities. Brookfield is a large detached family home providing accommodation in eight double bedrooms and five single bedrooms. The lounge, dining room and bedrooms are furnished to create a comfortable homely environment. There is a well-maintained garden to the rear of the property. Ample parking facilities are provided at the front and rear of the building. Brookfield DS0000006700.V262724.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s first annual unannounced inspection for the year. A number of residents were spoken to and asked about their life in the home. The manager was on duty, a second registered nurse and 4 care assistants on the morning shift. The inspection looked at a limited number of standards, so this report should be read together with the earlier report to get a full picture of how the home is meeting the needs of the residents living there. What the service does well: What has improved since the last inspection? Since the last inspection the management had improved communication within the home by providing staff and residents with new meetings where both staff and residents had the opportunity to influence daily activities within the home. The home had devised a plan to actively encourage staff to undertake training in line with their personal development. All staff had received training in the Protection of Vulnerable Adults since the last inspection and a number of study days had been attended, for example; diabetes, infection control and communicating with residents with dementia. Since the last inspection the home had received an Investors in People Award. Staff had been issued with new contracts of employment and job descriptions. It was pleasing to see that painting work had been carried out to the outside of the building. All dining room furniture had been replaced and the carpet in the rear lounge had been replaced. Brookfield DS0000006700.V262724.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brookfield DS0000006700.V262724.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 DS0000006700.V262724.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): 1, 2, 3 and 5. Prospective residents received a structured admissions procedure. EVIDENCE: The statements of purpose and service users guide were available for prospective residents. Residents’ needs were assessed before they moved into the home. The assessment included the involvement of the prospective resident, his/her representatives any other relevant professionals. Copies of the Multi Disciplinary assessment were available. Residents and their relatives were encouraged to view the home prior to making a decision about admission. Brookfield DS0000006700.V262724.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): 7, 8, and 10 Each resident had a detailed individual plan of care however some improvements were required to ensure residents’ health care needs are fully met. Shortfalls identified had the potential to place residents at risk. EVIDENCE: A selection of care plans were examined. The residents’ health and care needs were generally well documented and the manager clearly knew the resident well however a discussion highlighted a resident’s changing health care needs were not clearly recorded. The need to develop the care plans for “sleep” and to encourage the night staff to record their observations were discussed, as this would provide more detailed outcomes for the residents accommodated. Appropriate risk assessments had been included in the care plans, which included for example, consent for the use of bed rails. Brookfield DS0000006700.V262724.R01.S.doc Version 5.0 Page 10 It was pleasing to see there was evidence of the involvement of the resident/representative in the drawing up or review of some of the care plans examined. The daily nursing reports varied from very detailed to quite brief and not therefore always reflecting the actual care given. Equipment for the promotion of tissue viability and prevention/ treatment of pressure sores was available. Plans of care had some detailed recordings in relation to wound care however some improvements could be made by providing “wound mapping” and ensuring these are kept up to date. The staff at the home were seen to treat the residents with respect and dignity. Staff were seen talking to residents in a respectful and courteous manner. There was evidence of privacy and dignity included in the care plans. Letters of praise from relatives for the care and attention given by the staff were available. Brookfield DS0000006700.V262724.R01.S.doc Version 5.0 Page 11 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): 15 Residents were provided with a varied diet and meal times appeared a relaxing occasion. EVIDENCE: Menus were provided which offered residents choices. The lunch on the day of the inspection was home made stew and dumplings. Nutritional risk assessments were in place within the care plans. Residents spoke highly of the meals provided. The home did not have a menu on display however the staff said they consulted with the residents on a daily basis and provided alternatives upon request. The residents had been consulted regarding the menus and were enjoying buffet style teas at the time of the inspection. Meals were provided in the dining room, lounges or residents’ own bedrooms according to their preferred choice. New dining tables and chairs had been purchased since the last inspection. Brookfield DS0000006700.V262724.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): 16 and 18 Residents and relatives were aware of the homes complaints procedure. A policy was in place for the protection of vulnerable adults and following recent training staff had an understanding of how to put the policy into practice. EVIDENCE: The home had a complaints procedure in place and some of the residents were aware of how to make a complaint in the event of them wanting to. The Commission For Social Care Inspection has received one complaint about this service and a requirement was made for staff training, which has been addressed. Following an investigation under Trafford’s Multi Agency Policy for the Protection of Vulnerable Adults, a requirement had been made for all staff to undertake training in the implementation of this policy and in whistle blowing. The home was requested to re write their local policy and procedure. These requirements had been implemented. It was pleasing to see that following a discussion with some of the staff they were able to explain how they would respond to an allegation of abuse. Brookfield DS0000006700.V262724.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): The home was fit for its stated purpose and provided clean and comfortable surroundings. Parts of the premises had been refurbished making them more attractive for residents. EVIDENCE: There was evidence that the home had undergone some external painting and maintenance since the last inspection. The hall and stairways were due to be redecorated following this inspection. A review of the carpets was required in the bedrooms as some of these posed as a trip hazard and required stretching. The bedroom door for room 17 required attention, as it was not closing flush against its rebate. The bedrooms were personalised and homely. A number of residents have height adjustable beds and the programme of replacement was ongoing. Brookfield DS0000006700.V262724.R01.S.doc Version 5.0 Page 14 Laundry facilities were sited away from food preparation areas. Brookfield DS0000006700.V262724.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): 27, 29 and 30 The numbers and skill mix of staff were sufficient to meet the needs of the residents accommodated. Staff were encouraged to undertake training to assist them in developing the skills to meet the needs of the residents in the home. Some of the home’s recruitment practices placed vulnerable residents at potential risk of harm. EVIDENCE: The staffing levels appeared appropriate to meet the needs of the residents accommodated. It was pleasing to note that the home had increased their staffing levels between 2.00-4.30 pm in order to meet the assessed needs of the residents accommodated. Three of the home’s care staff had achieved NVQ level 2 qualification and four further staff were undertaking this course. Two staff members had achieved NVQ level 3. Plans were in place to improve staff training and to encourage staff to undertake courses of study, which may improve their knowledge relevant to their role within the home. Brookfield DS0000006700.V262724.R01.S.doc Version 5.0 Page 16 The home’s recruitment process was not fully compliant with those measures intended to protect vulnerable adults. The uptake of references for a new staff member had not been taken however she was on supervised shifts at the time of the inspection. There was no evidence that POVA first checks were being carried out on new staff employed prior to the receipt of full Criminal Records Bureau checks. This was raised with the responsible Individual at the time of the inspection and a prompt response was received and the requirements addressed. Brookfield DS0000006700.V262724.R01.S.doc Version 5.0 Page 17 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, 33 and 38 The manager was fit to be in charge of the home and fully able to discharge her duties. EVIDENCE: Since the last inspection it is pleasing to note that the manager had completed NVQ Level 4 qualification. Residents and staff spoken to felt they could raise any concerns with the manager, homeowner or the administrator. Since the last inspection the home had made an effort to improve communication and staff involvement within the home. Monthly meetings had been held and minutes were available. A resident’s committee had been established to discuss daily life issues. Accident records were audited on a regular basis and were clearly recorded. Brookfield DS0000006700.V262724.R01.S.doc Version 5.0 Page 18 A fire risk assessment was available and there was evidence of the fire safety checks being carried out as required. The last record of a fire drill was in March 2005 and the manager said a further test was imminent. Brookfield DS0000006700.V262724.R01.S.doc Version 5.0 Page 19 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 3 3 Brookfield DS0000006700.V262724.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 15 Requirement Timescale for action 31/01/06 2 OP8 12 3 OP24 13 4 OP29 19 The care plans must be kept under review and include the changing healthcare needs of the individuals accommodated. The care plan must include 31/01/06 detailed information on the treatment and progress of pressure sores. An audit of the bedroom carpets 31/01/06 must be carried out and those identified during the inspection must be stretched to minimise the risk of tripping. Two written references must be 31/01/06 obtained prior to the person commencing work at the home. 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 DS0000006700.V262724.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 DS0000006700.V262724.R01.S.doc Version 5.0 Page 22 - 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. 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