Inspection on 05/12/05 for Brookfields

This inspection was carried out on 5th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brookfields 19/03/09

Brookfields 06/02/07

Brookfields 08/07/05

Brookfields 12/01/05

Brookfields 12/07/04

Brookfields 05/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Brookfields 488 Burton Road Derby DE23 6AL Lead Inspector Anthony Barker Unannounced Inspection 09:10 5 December 2005 th 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 Brookfields DS0000002113.V262337.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. Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brookfields Address 488 Burton Road Derby DE23 6AL 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) 01332 343840 Brookfields P.N.H. Limited Susan Buxton Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34), Physical disability (5) of places Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th July 2005 Brief Description of the Service: Brookfields is a detached house, which has been adapted and extended as a care home. It is situated in Littleover close to local shops and a bus route. The Registered Company is Brookfields Private Nursing Home Ltd.The home provides nursing and personal care for up to 34 persons aged 65 years and over with physical health needs. Service users facilities are on 2 floors. The home provides 26 single and 4 double bedrooms. 29 rooms have en suite facilities. Access to the first floor is by stairs and 2 passenger lifts. The home has a dining room and 2 lounges on the ground floor. The garden is accessible to service users. Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 5.25 hours and was a routine unannounced inspection. The last inspection took place in July 2005 and was unannounced. Three residents, three visiting relatives, the Manager and the Home’s Administrator were spoken to and records were inspected. There was also a tour of the premises. Two residents were case tracked so as to determine the quality of service from their perspective. The focus of this inspection was on progress made on the requirements and recommendations made, and those standards not assessed, at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: The registered persons must ensure that a full assessment of a prospective residents needs is carried out and recorded prior to admission. Care plans must show involvement of service users/relatives and must include all risks and all needs. Approved locks must be fitted to bedroom doors. Care staff must receive supervision at least 6 times a year. The key to the cleaning materials cupboard must not be kept in the cupboard door lock. Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 6 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. Brookfields DS0000002113.V262337.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 Brookfields DS0000002113.V262337.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): 2&3 A full assessment of prospective residents’ needs was not being made prior to admission. EVIDENCE: A signed copy of residents’ contract (or terms and conditions if care managed) was being kept by the Home. Two files were examined as part of the case tracking process. The Home’s Admission Form and Prospective Patient Assessment Form had still not been updated to include residents’ social, religious or cultural needs. Residents’ needs were, therefore, not being holistically assessed, as at previous inspections. One relative said, “All my Mum’s needs are met here”. Another relative praised the Home for the care her mother receives. A third relative said staff were aware of individual residents’ needs and that “someone is always there to talk to”. Other aspects of standard 4 were not assessed on this occasion. Brookfields DS0000002113.V262337.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 & 10 Each resident’s health needs were set out in an individual plan of care but social care needs were not. Not all residents’ personal risks were being fully considered. Residents were being treated with dignity and respect. EVIDENCE: There was no recorded evidence, on the care plan of one resident who was case tracked, of this resident’s involvement in the care planning process though the Communication sheet showed there had been discussion with the resident’s spouse. However, there was no signature to support this. The care plan of this resident included care plan objectives to address general social needs but none were personalised to the resident. The Manager said that the Home’s Motivator had recorded some residents’ social needs in their care plans. From discussion with residents and their relatives it was clear that residents’ holistic needs were being met, in practice. There was, however, no overall policy of recording residents’ holistic needs. Files examined showed that care plans were being reviewed monthly. There were still no periodic review meetings held regarding those residents who were privately funded. Recorded risk assessments were still in need of improvement. One case tracked resident had a history of falls but no risk assessment had been written Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 10 regarding this. Also, risk assessment documentation gave no quantification of risk or actions to be taken to minimise or reduce risk. However, the Manager did describe one situation where an appropriate assessment of risk had been recorded and the resident’s family involved. Other aspects of standard 8 were not assessed on this occasion. Good practice was being followed in respect of recording the administration of residents’ medicines. Hand written entries had been signed, countersigned and dated. Other aspects of standard 9 were not assessed on this occasion. One staff member confirmed that the undignified practice of transferring residents through the lounge areas on a toilet chair frame without a seat cover had ceased. One relative was positive about staff attention to her mother’s dignity when she said she considered that her mother’s “clothing was well coordinated”. She added that “staff talk to mother as they care for her”. A resident’s nails were being painted by a member of care staff during this inspection, indicating a caring relationship. Two very positive letters of thanks, seen on one file, included reference to the observations of a relative in respect of “the professional and sensitive way in which the death of a resident was handled”. Other aspects of standard 11 were not assessed on this occasion. Brookfields DS0000002113.V262337.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): 13 Residents were enabled to maintain contact with family and friends and the local community. EVIDENCE: The working file of the Home’s Motivator was seen to include activities schedules and minutes of residents’ meetings. Additionally, one resident’s recreational interests were recorded. The Manager said that several residents have communion in their bedroom and one resident attends church with her husband. There were also some voluntary visitors to the Home, the Manager said. One relative said she felt her mother was adequately stimulated. Other aspects of standard 12 were not assessed on this occasion. The Manager said that all residents who have expressed a wish to have trips out have a relative who meets this need. Additionally, one resident has a member of staff who helps them to visit the town. Several use local shops with their relatives and some with staff. A number of relatives were seen today visiting a resident. The Manager agreed there was an ‘open door’ visiting policy and said that several residents have married partners visiting and who have meals with them. Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 12 Written information on external advocacy groups has been made available to residents and relatives through the Home’s Service Users’ Guide. Other aspects of standard 14 were not assessed on this occasion. Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 13 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 Residents were being protected from abuse. EVIDENCE: The complaints procedure was still not displayed in the Home although the Administrator said that it would be displayed in the Atrium soon. Other aspects of standard 16 were not assessed on this occasion. A letter to relatives was seen, enclosing a postal voting request form. This showed that residents’ rights to participate in the political process were being upheld. Other aspects of standard 17 were not assessed on this occasion. The Home’s policy and procedures on prevention of aggression had been amended to include residents and was displayed in the staff room. However, it did not make reference to legal aspects of restraint or to the importance of preventing situations developing. The Homes policy and procedure on the use of restraint had been updated in line with current guidance. Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 14 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): Residents were living in an attractive and well-maintained environment. EVIDENCE: Material standards in the Home were high, it was nicely decorated and bedrooms were well personalised. Other aspects of standard 19 were not assessed on this occasion. The Manager confirmed that suitably qualified persons had carried out an assessment of the premises and equipment. A report had not yet been typed but action had already been taken – for example, furniture had been moved. Other aspects of standard 22 were not assessed on this occasion. The Home’s Administrator said that there were plans to fit approved locks to bedroom doors by the New Year. She added that residents are always asked if they want to have locks fitted. Some bedrooms had lockable storage facilities but no record had been made to show that residents are given the option of having a lockable storage space provided. The Manager explained that Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 15 residents are asked about this. Other aspects of standard 24 were not assessed on this occasion. Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 16 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 Residents’ needs were being met an adequately resourced staff group. EVIDENCE: Staffing levels were discussed with the Administrator and were found to be satisfactory. Cover at mealtimes had been given particular attention. The staffing rota was examined and found to be satisfactory. No agency staff were being used and there was low staff turnover, the Administrator said. Student nurses and Age Concern trainees were also part of the Home’s resources. Two staff induction files from 2002 and 2003 were examined and were found to be satisfactory. Other aspects of standard 30 were not assessed on this occasion. Brookfields DS0000002113.V262337.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): 33 & 36 The Home was being run in the best interests of residents. Residents were not fully benefiting from appropriately supervised staff. EVIDENCE: The Administrator said that regular full staff meetings were held at least four times a year. Other aspects of standard 32 were not assessed on this occasion. The Administrator said that the registered provider visits the Home at least twice a month and records in the diary the names of residents, staff and visitors spoken to. Any issues arising are recorded but no separte record is kept. The Administrator was handed sample forms that could be used to record monthly un-announced visits as required in Regulation 26. Evidence of the Home’s quality assurance system comprised… • minutes of residents’ meetings, • two very positive letters of thanks from relatives, Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 18 • good monitoring practices from the Manager regarding the recording of medicines administered, • link nurse roles covering the areas of tissue viability, infection control, continence promotion, nutrition and dysphasia. Recorded evidence was seen of qualified staff determining and recording whether residents are subject to power of attorney or guardianship orders on admission. Other aspects of standard 35 were not assessed on this occasion. The Administrator said that staff supervision was ongoing and rated as important. She said there was a Nursing Skills Co-ordinator as well as a Training Officer on the staff group. However, there was no formal system of one-to-one supervision meetings with staff and no written supervision policy. At a previous inspection some residents’ wheelchairs had been observed to be without footrests. The Manager said the majority of residents used footrests now and a ‘Footrest Waiver’ form was seen on one file for use when a risk of injury from a footrest is identified. Evidence was seen on one file of residents’ moving and handling assessments and care plans showing how staff are assisting them to move/transfer. Radiator covers were seen to be in place and mixer valves placed near hot water taps to minimise the risk of scalding. The key to the cleaning materials cupboard was seen to be in the cupboard door lock. Other aspects of standard 38 were not assessed on this occasion. Brookfields DS0000002113.V262337.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 X 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 2 X X Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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(1)(a) Requirement The registered persons must ensure that a full assessment of a prospective residents needs is carried out and recorded prior to admission - as detailed in Standard 3.3 (Previous timescale was 01/09/05) Care plans must show involvement of service users/relatives in all stages of care planning. Service users care plans must include all risks. Service users care plans must include all needs.(Previous timescale was 30/6/04) Carry out a programme to fit approved locks to bedroom doors. (Previous timescale was 31/10/04) The manager must establish formal supervision for all staff. Care staff must receive supervision at least 6 times a year. (Previous timescale was 31 October 2004) The key to the cleaning materials cupboard must not be kept in the cupboard door lock. Timescale for action 01/02/06 2. OP7 OP8 13(4c) 15(1)(2c) 01/02/06 3. OP24 12(4)(a) 01/02/06 4. OP36 18(2) 01/02/06 5. OP38 13(4)(a) 01/01/06 Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 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. 4. Refer to Standard OP7 OP8 OP16 OP18 Good Practice Recommendations Periodic, multi-professional review meetings should be held for all residents who are privately funded. (This was a recommendation from 12 July 2004) Risk assessment documentation should quantify risk and show actions to be taken to minimise or reduce risk. The Complaints Procedure should be clearly displayed in the home. (This was a recommendation from 12 July 2004) The Home’s policy and procedures on prevention of aggression should make reference to the legal aspects of restraint and indicate the importance of preventing situations developing. The Homes statement of purpose, service users guide and service users care plans should clearly show that service users are given the option of having a lockable storage space provided. (This was a recommendation from 12 January 2005) The Registered Person should use a standard form to record monthly un-announced visits as required in Regulation 26.(This was a recommendation from 5 March 2004) The home should provide a written policy on staff supervision. All staff should be made aware of this.(This was a recommendation from 5 March 2004) 5. OP24 6. OP33 7. OP36 Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Brookfields DS0000002113.V262337.R01.S.doc Version 5.0 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. 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!