Inspection on 17/01/06 for Brookfield Christian Care Home

This inspection was carried out on 17th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Christian Care Home 28/10/08

Brookfield Christian Care Home 29/11/07

Brookfield Christian Care Home 17/05/06

Brookfield Christian Care Home 19/07/05

Brookfield Christian Care Home 09/06/04

Brookfield Christian Care Home 29/04/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech 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 Christian Care Home Little Bury Oxford OX4 7UY Lead Inspector Annette Miller Unannounced Inspection 17th January 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 Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 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 Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Brookfield Christian Care Home Address Little Bury Oxford OX4 7UY 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) 01865 779888 01865 779444 brookfield@trinitycare.co.uk Trinity Care (Brookfield) Ltd vacant Care Home 66 Category(ies) of Dementia - over 65 years of age (33), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (33) Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. On admission persons should be aged 60 years and over. The total number of persons that may be accommodated at any one time must not exceed 66, of which 33 may be in either the DE(E) or MD(E) category. 19th July 2005 Date of last inspection Brief Description of the Service: Brookfield Christian Care Home is a purpose built home situated on the outskirts of the Greater Leys area of Oxford, overlooking open countryside. The home is registered to provide care for up to 66 residents aged 60 and over. Accommodation is provided on two floors. There are spacious lounges and dining rooms on both floors and all bedrooms are single with en-suite facilities consisting of a washbasin and toilet. Spacious bathrooms with assisted baths are available. There is a small garden surrounded by fencing leading from one of the ground floor lounges. Ample parking is available at the front and side of the home. Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector from 10.00am to 4.00pm. During this time a tour of the building took place and documents were examined. Residents and staff were spoken to in order to obtain a range of views about the home. A conversation was also held with a physiotherapist who was visiting. Mrs Susan Chapman (acting registered manager) was present in the home until 2.00pm, when she had to leave to attend a previously arranged appointment. She was appointed as the proposed registered manager in September 2005 and has submitted her application to the Commission for Social Care Inspection (CSCI) for her appointment to be approved. The procedure includes an interview to establish ‘fitness’ to manage the home and, until the required checks and interview have been completed, Mrs Chapman has the title of ‘acting registered manager’. The inspector was made to feel welcome by all staff and appreciated their cooperation. The last inspection of the home took place on 19th July 2005 and some of the standards assessed during that inspection were not reassessed during this inspection. Therefore, to gain an overview of the home this report should be read in conjunction with the report dated 19 July 2005. What the service does well: What has improved since the last inspection? Substantial maintenance work has been carried out on the fire alarm system. Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 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 Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 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 Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 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 Written information about how the company refunds NHS money to residents for their nursing care is not provided and, therefore, some residents may not be fully aware of their rights in this matter. EVIDENCE: The home’s Statement of Purpose and Service User Guide were being updated at the time of inspection and were not available for inspection. NHS nurses assess residents after admission to determine the level of nursing care that is needed. The amount of money paid by the NHS for this care is paid directly to the company (Southern Cross Healthcare Services Ltd) but there is no written information provided to residents about how the money is reimbursed. This is required. Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 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): 8 and 10 The health needs of service users are met with evidence of good multi-disciplinary working taking place on a regular basis. EVIDENCE: Residents are assessed before admission to identify their health and social care needs to ensure that the home can provide the care that is needed. Assessment includes checking skin condition for potential risk of pressure sores and pressure relieving mattress and cushions are provided as and when needed. Nutritional needs are also assessed and recorded on the nutritional assessment tool currently used. The manager confirmed the nationally validated assessment tool used by community dieticians in Oxfordshire - the Malnutrition Universal Screening Tool (MUST) was being considered. This was a recommendation made at the last inspection. A physiotherapist said she thought the care provided was good. She regularly visits the home to give private treatment to one resident and finds staff to be helpful and friendly. GPs visit regularly to give medical care. Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 Page 10 All bedrooms are single providing residents with their own personal space. The inspector saw staff knock on bedroom doors and wait before entering. Most residents are called by their Christian names and the inspector was assured this was at the request of each resident. A carer confirmed residents are asked on admission for their preference regarding the term of address to be used. Also, that matters concerning privacy and dignity are covered during induction training. Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 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): 14 Rules and regulations are kept to a minimum in order to uphold residents’ personal choices as to how they spend their time. EVIDENCE: Residents are helped to exercise choice and control over their lives in a variety of ways, such as what they have to eat and what activities they take part in. They are encouraged to go to the dining room for meals as this provides a pleasant social environment, but can choose to stay in their rooms to eat if this arrangement is preferred. The bedrooms inspected looked homely and comfortable and personal possessions were very much in evidence. Care plans are kept on computer at present, although some paper records are also kept and can be shown to residents who ask to see them. The manager has information about advocacy services to give to residents who need this service. Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 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): 18 The home has systems to protect residents from abuse but formal training has not taken place. This needs to be arranged to provide residents with assurance that they will be protected from possible risk of harm or abuse. EVIDENCE: The home has policies and procedures in place to protect vulnerable adults from abuse. However, staff spoken to could not remember attending training on the protection of vulnerable adults and this must be arranged. The manager was unable to say if the home had a copy of the Oxfordshire interagency guidelines for the protection of vulnerable adults. A copy should be obtained and brought to the attention of all staff working in the home during training, and for senior staff to be aware of the local guidance in relation to how any concerns or allegations are investigated in Oxfordshire. Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 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 There are some communal rooms that would benefit from redecoration but, overall, the standard of décor is good providing residents with a pleasant environment in which to live. EVIDENCE: The reception area has been redecorated since the last inspection and provides a pleasant entrance to the home. Corridors are wide and bright, and most areas are well maintained and decorated. However, wallpaper in two communal rooms was ripped and these rooms should be treated as a priority, together with the sun lounges identified at the last inspection, for redecoration. The manager explained that maintenance work to heating pipes had recently occurred in the sun lounges and redecoration was planned. Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 Page 14 There is a small garden leading off a ground floor lounge that residents can use. Garden tables and chairs are provided. There is a larger area of lawn at the side of the home beyond the car park, but this is an extension of the home’s frontage and is not secured with fencing. Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 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, 28 and 29 The number of staff on duty exceeded the minimum number required and this indicated that staffing on the day of inspection was satisfactory. The number of carers with an NVQ award is low and this training needs to be increased for residents to be assured that carers have the appropriate level of knowledge and skills for the work undertaken. The manager must ensure that the required recruitment checks are carried out to provide residents with assurance that they will not be put at risk. EVIDENCE: There were 60 residents in the home – 29 on the ground floor and 31 on the first floor. The number of staff on duty during the day consisted of four trained nurses and ten carers. This was above the minimum number required by two carers. During the evening there were two trained nurses (one on each floor) and a total of 11 carers. This was one carer above the minimum required. A minimum ratio of 50 trained members of care staff has not yet been achieved. Only four out of 38 carers have completed NVQ training, with ten carers currently on the training. The company should plan for more staff to be enrolled on NVQ training. Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 Page 16 Recruitment files for three members of staff were randomly selected for inspection and, whilst most of the information and documents had been obtained, the following information was missing: • the professional identity number (PIN) of a registered nurse had not been verified with the Nursing and Midwifery Council (NMC), but was done during the inspection and confirmation of the check faxed through for the inspector to see. a carer had been appointed without a full-work history and this is needed to enable the manager to check gaps in employment. • Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 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, 35 and 36 There are no formal quality assurance and quality monitoring systems in place and these need to be developed in order to provide residents and other key people an opportunity to make comment about the services provided. The system of formal supervision of staff is not fully in place. EVIDENCE: Mrs Chapman was appointed as the proposed registered manager in September 2005. She is a registered nurse and has previously managed care homes for older people and is currently studying for the Registered Manager’s Award. Mrs Chapman said that management procedures that were new to her, for example recruitment procedures, were being addressed through training provided by the company. Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 Page 18 At the time of inspection Mrs Chapman had submitted her application to CSCI for the necessary checks and interview to be arranged. Until this procedure is completed, Standard 31 cannot be given a fully met score. Mrs Chapman is the home’s health and safety representative and attended a day’s training in January 2006. She has held one meeting with her heads of department to discuss health and safety issues and further meetings are planned. There are no formal quality assurance and quality monitoring systems in place and these should be introduced, for example through anonymous user satisfaction questionnaires, to provide an opportunity for residents and other key people to comment on the home’s services. A meeting was held during January 2006 for residents and relatives, attended by Mrs Chapman and an operations manager from within the company. The inspector was told the meeting was very well attended and also well received. Another meeting has been arranged. Staff meetings are also held. The home has policies and procedures for looking after residents’ pocket money. Receipts are issued for money received and there are computer records of each resident’s income and expenditure. Residents’ pocket money is placed in a bank account that is separate to the company’s funds. The administrator confirmed that the company carries out regular financial audits. CSCI expects formal supervision meetings to occur at least six times a year. This supervision is important because it gives the opportunity for all care staff to have a ‘one-to-one’ meeting with their mentor/manager and to discuss any training needs they may have and their progress in their job. This is an area that needs to be developed. Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 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 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 3 28 1 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X X Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 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 OP1 Regulation 5a Requirement The company must arrange for written information to be produced that explains to residents how they receive NHS money for nursing care. Timescale for action 31/03/06 2 OP18 13(6) The manager must arrange for 30/04/06 all staff to receive training on protecting vulnerable adults from abuse. The manager must ensure that the necessary information and documents are obtained prior to the appointment of staff. 17/01/06 3 OP29 19(1) Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP18 OP19 OP29 Good Practice Recommendations Obtain a copy of the Oxfordshire multi-agency guidelines for the protection of vulnerable adults against abuse. Arrange for redecoration of the sun lounges, main lounges and dining rooms where wallpaper is ripped. Make arrangements to increase the number of carers on NVQ training by providing the help and support needed to achieve this. Develop quality assurance and quality monitoring systems to obtain the views of people using the service. Implement a programme of regular formal staff supervision and maintain records. 4 5 OP33 OP36 Brookfield Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Christian Care Home DS0000027141.V279066.R01.S.doc Version 5.1 Page 23 - 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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