Inspection on 02/07/09 for Brookhaven

This inspection was carried out on 2nd July 2009.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brookhaven 09/07/08

Brookhaven 06/12/07

Brookhaven 17/01/07

Brookhaven 12/01/06

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOME ADULTS 18-65 Brookhaven Gough Lane Bamber Bridge Preston Lancashire PR5 6AQ Lead Inspector Vivienne Morris Key Unannounced Inspection 2nd July 2009 10:30 Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookhaven Address Gough Lane Bamber Bridge Preston Lancashire PR5 6AQ 01772 315894 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) jon.whitton@optimacare.co.uk Optima Care Limited Manager post vacant Care Home 34 Category(ies) of Dementia (6), Mental disorder, excluding registration, with number learning disability or dementia (34) of places Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 34 service users to include: Up to 6 service users in the category of DE - (Dementia). Up to 34 service users in the category MD - (Mental Disorder excluding learning disability or dementia). 9th July 2008 Date of last inspection Brief Description of the Service: Brookhaven provides accommodation for up to 34 adults, aged between 18 years and 65 years, who are suffering from mental health problems. The home is registered for a small number of places for older people with a diagnosis of dementia. However, the home is no longer admitting people of 65 years of age or above. The accommodation is provided on two levels served by a passenger lift. The majority of bedrooms are single, although a few double rooms are available for those wishing to share facilities. People moving into Brookhaven are able to bring their own furnishings to the home and are encouraged to retain their personal possessions. Although only a small number of rooms have en-suite facilities, toilets and bathrooms are located at convenient intervals throughout the home. A variety of lounges and a large dining room are provided, although people have the choice of dining within the privacy of their own rooms, if they choose to do so. Brookhaven is conveniently situated on the outskirts of Bamber Bridge and is easily reached by road and public transport, with the motorway network being close by. The scale of charges at the time of this site visit ranged from £469:50 to £2162:00 per week. Additional charges were being incurred for hairdressing, toiletries, clothing, outings and personal luxuries. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This unannounced site visit to the service was conducted over one day in July 2009 and formed part of the key inspection process. During the course of the site visit, discussions took place with those living at the home, as well as relatives and staff. Relevant records and documents were examined and a tour of the premises took place, when a random selection of private accommodation and all communal areas were seen. Comment cards were received from three people using the service and their feedback is reflected throughout this report. No comment cards were received from staff. Every year the provider completes an Annual Quality Assurance Assessment (AQAA), which is a self-assessment and which gives information to the Commission about how the home is meeting outcomes for people using the service and how the quality of service is monitored. It also gives us some numerical details and some of this information forms part of this inspection report. We observed the activity within the home and ‘tracked’ the care of three people during our visit to this service, not to the exclusion of other residents. The total key inspection process focused on the outcomes for people living at Brookhaven and involved gathering information about the service from a wide range of sources over a period of time. The Care Quality Commission had received one complaint about this service since the last inspection which was looked at during this key inspection. What the service does well: The pre-admission needs assessment which was seen was extremely detailed and provided staff with a clear picture of this individual’s needs so they were able to decide if they could give the care and support required by this person. Whilst we saw one good example of a pre-admission needs assessment, we found that in general improvements were required in this area, these findings are addressed later in the report. Some care plans were well written, providing staff with clear guidance about the needs of people and the desired outcomes, so that staff were aware of individual goals. People living at the home were encouraged to maintain contact with family, friends and the local community. Outings were arranged and small group Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 6 activities were provided. People were able to go out accompanied or alone within a risk management framework and their independence was seen to be respected, although this could have been better recorded within the care plans. When asked what the service does well the manager wrote on the self assessment, ‘We have a dedicated Activities Coordinator whose role is to consult and plan activities, both in and out of the home that reflect the wishes of the individuals concerned. This person works in conjunction with colleagues, all of whom have responsibility for ensuring that these plans are actioned’ In general, the management of meals was satisfactory. The food served on the day of our visit looked appetising and it was clear that people were given the same opportunities by the provision of foods in line with their culture and religion. The health care needs of people living at the home were being met by the input of a wide range of external professionals and by staff having the knowledge and skills to look after the people in their care. Complaints were well managed and those living at the home were protected by the policies and procedures adopted by Brookhaven. The control of infection was good and clinical waste was being disposed of correctly. Policies and procedures were in place so that staff were made aware of what measures to take in order to prevent cross infection. A good percentage of care staff had achieved a recognised qualification in care to ensure that the care and support needed was delivered and so that unqualified staff could be appropriately supervised. The recruitment procedures adopted by the home were robust so that people living at Brookhaven were protected from abusive situations. The systems and equipment within the home had been appropriately checked to ensure it was in good working order. What has improved since the last inspection? The plans of care had been reviewed every six months or more often if needed and people’s changes in need were reflected well. It was pleasing to see that an activities co-ordinator had been appointed since our last key inspection and it was evident that some improvements had been made in this area so that the lifestyle of the people living at the home was better. The management of medications had improved since the last inspection so that they were being handled in a safe manner. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 7 The provision of staff training had improved since our last inspection, so that staff received regular mandatory training and the induction of new staff starting work at the home was more thorough to ensure that they were confident and competent to do the job before they worked alone. Minutes were being retained of any meetings held so that those concerned could establish what topics were discussed and could obtain any relevant information. The electrical installation had been serviced since we last visited to ensure it was safe for use. What they could do better: Everyone moving in to the home could have had their needs assessed before they were admitted to allow the staff team to make sure that they could provide the care and support needed by each individual. When needs assessments had been conducted then this information could have been retained on people’s care files so that staff were aware of individual needs on admission to the home. The plans of care could have been more person centred and told staff in more detail how people’s personal and mental health care needs could be met and how people could be supported to maintain their leisure interests whilst living at the home. The people living at the home or their representatives could have been involved in the care planning process and the management of risks, so that they had the opportunity to have some input into the care and support being delivered. Although significant improvements had been made in relation to the provision of activities, further improvements could be made so that individuals are provided with leisure interest in accordance with their plans of care. People’s choices could have been respected more and staff need to understand that some people living at the home may not always remember what they had ordered for their meals and therefore some flexibility needs to be introduced in this area. The environment could have been upgraded and made more modern, so that more pleasant surroundings and improved facilities were provided for the people living at Brookhaven. Staff could have received more specific training in relation to the individual needs of people living at the home, such as, diabetes and schizophrenia. The quality of service provided could be monitored more thoroughly by conducting a wider range of audit trails and consulting people with an interest in the home in a more structured way, with the outcome of surveys being published so that prospective residents can see what life is like at Brookhaven. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, personal and social care needs of people had not always been assessed before they moved into the home to ensure that the staff team could provide the care and support needed. EVIDENCE: The care of three people living at Brookhaven was ‘tracked’ during the course of our inspection. Of the three care records examined, there was only one that contained an assessment of the individual’s needs before they were admitted to Brookhaven. This assessment was extremely detailed, providing very clear information about the needs of this person so that the staff team were confident that they could provide the care and support required. The plan of care seen for this person was generated from the information gathered before they came to live at Brookhaven, showing that all their assessed needs were considered when planning their care. It was later established that the information gathered about another person’s needs had been archived and so was not available for staff to see. However, a pre-admission assessment for a third person had not been conducted to allow staff to decide if they could meet this person’s assessed needs. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 11 All three people who sent us comment cards and who live at the home said that they were not asked if they wanted to move in to this home and were not given enough information before they moved in. Part of a recent complaint about the home was that the brochure available for people did not depict a picture of Brookhaven, but that of a different care service. We looked at the current brochure which clearly showed a picture of Brookhaven. When asked what the service does well the manager of the home wrote on the self-assessment, ‘An initial pre admission assessment is undertaken, in most instances, by at least two members of the multi disciplinary team. This assessment allows us to establish the particular requirements and needs of the individual client. During the assessment there is opportunity for us to inform potential clients of the service that we can offer, and explain how we can tailor the service to meet their individual needs. Once the pre-admission assessment has taken place there is opportunity for the client to visit the placement, with support workers and family as required, to look at the placement and discuss any outstanding issues and questions. This enables the client to make an informed choice as to whether they feel the placement is suitable. While visiting they will be able to discuss room decoration and personalisation’. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ assessed needs are recorded in a plan of care. They are usually supported to make informed decisions about the routines of daily life within a risk management framework, although this is not always documented. EVIDENCE: The three care plans examined varied in quality. One provided staff with extremely detailed information about the needs of the individual and the desired outcome, but failed to give guidance about how the outcome was to be achieved. The plan of care for another person provided basic information only in relation to personal hygiene and mental health needs and therefore was not person centred and did not provide staff with clear guidance about how these needs were to be met. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 13 The records for a third person contained sufficient detail, but the plan of care focused on the individual’s problems and did not show how they could be supported to do things they were able to do. The plans of care had been reviewed every six months or more often, if required, and any changes in needs were reflected well. However, there was not always evidence that the person living at the home or their relative had been involved in the care planning process so that they had the opportunity to say how they preferred the care and support to be delivered. Two of the three people living at the home who sent us comment cards said that they sometimes make decisions about what they do each day and a third said they usually did. A wide range of risk assessments had been conducted and those living at the home were evidently able to take risks within a risk management framework. However, it was established that some people were able to take controlled risks which were not recorded in the plan of care to make staff aware of the risk strategies in place. When asked how the service had improved in the last twelve months the manager of the home told us, ‘We have improved not only the care plans but the whole care planning process, so that they now are evidence based, action orriented, and collaborative. We now have a Social Worker who is able to respond to the individual concerns of residents. All staff work under the guidance of the multi-disciplinary team’. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 and 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In general, those living at the home are able to experience a private and dignified lifestyle, which matches their expectations in relation to social care, leisure activities and hobbies, both inside the home and within the local community. EVIDENCE: It was pleasing to see that an activities co-ordinator had been appointed since our last key inspection and it was evident that some improvements had been made in this area so that the lifestyle of the people living at the home was enhanced. At the time of our visit a group of residents were looking forward to visiting Blackpool zoo that day and people we spoke with told us about different community based activities they took part in, such as, visiting the local pub, park, supermarket and leisure centre. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 15 One person living at the home and his relatives told us that his key worker accompanied him to meet family and friends for a birthday meal at a local restaurant, which was pleasing to hear. We noted that the conservatory had been converted into an art studio, which was tastefully decorated and nicely furnished, providing a pleasant area for people to work in or just simply view the works of art displayed by the people creating them. A basic activity programme was in place, but it was established that activities were very much based on the individual preferences of people living at the home. Although this area was much better than when we last visited the service, we felt that further improvements could still be made so that everyone living at the home could be involved in some form of activity identified within their plan of care. One person living at the home told us, “it is marvellous here” and a relative said, “The staff really try very hard”. The care plans seen included the importance of people maintaining contact with family and friends and records were retained of those important to them. It was evident that people were supported to go out accompanied or alone so that community contact was continued while people lived at Brookhaven. However, one care plan incorporated the importance of maintaining privacy and dignity and it detailed the individual’s leisure interests, but failed to identify how this person could be supported to maintain these interests whilst living at the home. People living at the home were seen to have flexible lifestyles and freedom of movement was evident. Plans of care showed that people were supported to go on leave to spend time with their family or friends and that they were assisted to maintain relationships whilst living at Brookhaven. The plans of care seen showed that people were given choices and that their preferences were taken into consideration. However, this information could have been extended to incorporate more details in relation to people’s abilities and independence. When asked on the comment cards, ‘can you do what you want to do during the day, evening and at weekend?’ Two people said no and a third did not answer the question. We were told that a variety of external people visit the home to do presentations for staff and those living at the home, such as representatives from the local college. The meals served at the time of our visit looked appetising and people spoken to told us that they had enjoyed their lunch. The menu displayed coincided Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 16 with the meal served, which was pleasing to see. However, those we spoke to told us that they did not know what they were having for lunch and one of these people added, “It’s a surprise”. However, we were shown a list of what people had previously ordered for their meals. Special diets were being catered for, including those in relation to religious needs and cultural beliefs, including Halal meat and Caribbean food. One relative spoken to said that sometimes meals could be better. She said, “Sometimes they are not very appetising”. The resident agreed with this saying that he would like to see more curries on the menu. The plan of care for one person living at the home showed that he would be provided with an alternative meal if required, due to him forgetting what he had ordered. However, at lunch time one staff member was overheard telling a resident that they could not change their mind about what they had already ordered, stating, “that’s not how it works”, which showed an inflexible approach to dietary choices. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Brookhaven, in general receive appropriate personal and health care support and the management of medications is good. EVIDENCE: It was pleasing to establish that a social worker was attached to Brookhaven and the sister home on the same site. We spoke with this staff member who said, “The staff here really do a very good job. They are excellent”. There was a lot of evidence to show that a wide range of external professionals were involved in the care of people living at the home to ensure that their health care needs were being appropriately met. Information was widely available for staff about people’s medical conditions and those spoken to were aware of the medical needs of people in their care. We were pleased to note that those working at the home had received Mental Capacity Act training and Deprivation of Liberty Safeguards (DOLS) training, so that staff were aware of current regulations and new guidance. Some plans of Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 18 care showed that assessments had been conducted to determine people’s capacity to consent to treatment and a DOLS representative was already involved with one person living at the home. The plans of care examined could have been more detailed and person centred in relation to the support people needed to meet their personal hygiene needs. In relation to the management of medications, some good practice was seen, including a record of why and how often ‘as required medication’ could be given with any possible side effects and what knowledge the resident has about their own medications. However, quite a number of instances showed that hand written entries on the Medication Administration Records were not always signed, witnessed and countersigned in order to avoid any transcription errors. The receipt of medications was recorded appropriately and a list of specimen signatures was available so that the administering nurse could be easily identified. The policies and procedures of the home in relation to the management of medication had been reviewed and updated, so that staff were aware of current guidance and legislation. Records were available to show that two staff members had checked any medication being given to those going on leave to ensure that appropriate doses were being dispensed. When asked what the service does well the manager of the home wrote on the self assessment, ‘All residents are treated with dignity and respect and we have a champion linked to the national campaign for Dignity & Respect. We have a good gender/ethnic minority mix within the staff group and we are sensitive to gender related issues in day to day practice that require assistance with personal needs. All residents are allocated a Named Nurse and attempts are made wherever possible to match people’s preferences for staff of a similar gender, ethnicity, etc’. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Those living at Brookhaven are adequately protected from abusive situations and systems are in place to ensure that complaints are well managed. EVIDENCE: A good complaints procedure was in place at the home, which was prominently displayed and which was available in the Service Users’ Guide so that people living at the home and any other interested parties knew how to make a complaint, should they so wish. A system was available for recording any complaints received, including the outcome of any investigation conducted, so that a clear audit trail could be followed. People spoken to told us that they would know how to make a complaint if they needed to do so and that if they had any concerns they would feel comfortable in approaching the staff working at the home. Policies and procedures were seen in relation to protecting the people living at Brookhaven. Staff spoken to said that they would know what to do if they were concerned about the welfare of anyone living at the home and were aware of whistle blowing procedures in place. Records showed that staff had received training this year in relation to safeguarding procedures and the protection of vulnerable adults to ensure that they would know what to do if they were concerned about someone living at the home. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 20 Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home needs to be upgraded in order to provide a more comfortable and modern environment for the young adults living at Brookhaven. EVIDENCE: Since our last key inspection we received an anonymous complaint about the environment of the home. We were told that the home was in a very poor condition and that the facilities and bathrooms were very poor. We decided that we would look at these issues as part of this key inspection. We toured the premises and noted that some work had been done to the environment since our last key inspection, but that further improvements needed to be made. Some areas had been decorated and new flooring laid in parts of the home. However, the environment, in general, needed to be upgraded and facilities needed to be modernised for this group of people living at the home. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 22 We were shown plans of a refurbishment programme and were told work would start soon. However, it was disappointing that more improvements were not evident at the time of this visit to the service as at the last key inspection, we were told that extensive refurbishment and upgrading was imminent. The findings of our tour of the premises were as follows: Games room The standard of cleanliness in this area was better than at our last key inspection. However, the room was still ‘stark’ and unwelcoming. The furniture was old and in need of replacement or renovation. An armchair was stained and in poor condition and in need of replacement. The flooring at the skirting boards was in poor condition and in need of attention. Bathroom first floor We found this area in very poor condition. This bathroom was in need of urgent decoration. There were cigarette burns in the floor covering, which needed replacing. There were also cigarette burns in the bath, which needed attention. The bath panel on one side of the bath needed painting and the panel on the other side was missing and in need of replacement. Bathroom ground floor This bathroom was in poor condition. The linoleum was split and there were damp patches on the ceiling, which needed attention. The pipe work to the shower unit was leaking and in need of repair. Reception The double glazing units needed to be resealed as there was condensation between the glass panes. Lounge off the conservatory This area had been redecorated and a new carpet had been fitted. However, most armchairs in this area were in poor condition and in need of replacement. The carpet in one bedroom was in very poor condition and in need of replacement. This was pointed out to the management of the home at the time of our visit. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 23 The areas above need addressing so that a more pleasant environment is provided for the people living at the home. One resident told us, “I am happy with my bedroom. It is comfortable and I have my own things in it”. The laundry department was well managed and fit for purpose. We had a discussion with the laundry assistant who told us that she did not encounter any problems and that there was sufficient equipment provided, which was repaired quickly if it broke down. We noted that clinical waste was disposed of in the correct manner and those policies and procedures in relation to infection control were in place. The training matrix showed that five staff had completed infection control this year and we were told that this training was provided on a rolling programme. The home’s self-assessment did not identify what improvements had been made in the last twelve months, but the manager told us of planned improvements during the next twelve months, ‘we have well advanced plans for the first phase of a major refurbishment of the building. Phase 1 will comprise conversion of some currently unused bedrooms to training rooms, rehab kitchen, and client laundry. The refurbishment will be carried out in stages because of the need to minimize disruption for the residents’. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Those living at the home are adequately protected by the recruitment procedures and their needs are consistently met by the skill mix, competence and number of staff working at the home. EVIDENCE: We established that there were 14 care staff employed at the home and 11 of these had achieved a recognised qualification in care showing that 78.5 of care staff were appropriately trained to deliver the care required and to support unqualified staff. This was pleasing to see. The duty rota showed that qualified nurses were on duty at all times to ensure that the nursing needs of people living at the home were being met. Those living at Brookhaven who we spoke with were very happy with the attitude of staff looking after them and they were able to tell us who their key workers were. One relative told us, “Our son’s key worker, Michael is excellent”. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 25 The records of two staff members appointed since we last visited the home were examined. We found that the recruitment practices had improved, which was pleasing to see. Appropriate checks had been conducted before people started to work at the home to ensure that people living at Brookhaven were safeguarded. We saw the staff training matrix, which showed that all staff routinely completed a selection of mandatory training courses to ensure they were competent in essential aspects of the care service. A training session for staff was taking place during our visit to the service. Induction records were retained on staff files, which were satisfactory, showing that people starting to work at the home were given all relevant information about the service and about the people living there before they worked unsupervised. Records showed that some training was provided in relation to the general needs of people as a group, such as the Mental Health Act and the Deprivation of Liberty Safeguards (DOLS), which was considered to be good practice. However, it is recommended that specific training be provided more regularly for staff in relation to the individual medical and mental health needs of those living at the home, such as, diabetes and schizophrenia. When asked what improvements are planned for the next twelve months the manager told us, ‘We intend to further develop training with more mental health specific topics available. Some staff will be seconded to external training courses. We intend to examine the extent to which we could involve residents in the recruitment and selection process. We have begun to implement the recovery model and this will be a major project for us for the next year and beyond’. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The quality of service provided is not monitored thoroughly enough and the home has not demonstrated management stability for some time. The health and safety of people living at Brookhaven is not always met. EVIDENCE: This service has been without a registered manager for a long period of time, which has concerned the Care Quality Commission. However, we were told that the current manager of Brookhaven has submitted her application to become the registered manager of the home, so that there will be some stable management support for the people living there and for the staff team. We saw that minutes of a variety of meetings were retained, so that those concerned were aware of discussions which took place. The minutes seen provided some good ideas, such as organised theme nights with a take away, Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 27 such as Chinese or Indian food and bar-b-ques in the summer with monthly trips out. The latest environmental audit of the home, which was conducted in June this year, showed that a lot of repairs were needed to bring the home up to a good standard for the people living there. The quality of service provided could be monitored more thoroughly by introducing clear audits trails in areas, such as care planning, medications, meals, laundry, social activity and staff training. A more structured approach could have been adopted towards gathering feedback from people using the service, their relatives, staff and stakeholders in the community so that the home could regularly assess if the service was meeting goals for the people living at Brookhaven. We determined that six out of the eleven requirements made at the last key inspection had not been met, which was disappointing as an action plan had been sent to the Care Quality Commission detailing how the requirements were to be addressed. It is important that requirements made are addressed within the appropriate time scale so that a good quality of service is provided for the people living at the home and this would be enhanced by a stable management structure, which from this visit to the home seems to be developing. We examined the accident records, which were completed well and information was recorded accurately. Clinical waste was being disposed of correctly and a contract was in place with a paper audit trail to demonstrate collection of clinical waste batches. Service certificates were examined at random to ensure that systems and equipment within the home were being appropriately checked by an external contractor so that people’s health and safety was maintained. However, due to the amount of maintenance work required the health and safety of people living at the home was not always promoted. When asked what improvements have been made in the last twelve months the manager told us, ‘Increased awareness of safety and security. Rostered training sessions to improve attendance. We are currently working towards becoming a placement area for student nurses’. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 2 X X 2 X Version 5.2 Page 29 Brookhaven DS0000065154.V376812.R01.S.doc YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(1) Requirement As far as practicable everyone moving in to the home must have had their needs assessed before they are admitted. This enables the staff team to be sure that they can provide the care and support needed by each individual. The plans of care must clearly identify all the assessed needs of people living at the home in relation to personal and social care needs and clear guidance must be recorded to show how these needs are to be fully met. Timescale of 31/08/08 not met. People living at the home, or their relative, must be given the opportunity to be involved in the planning of their care. Timescale of 31/01/08 and 31/08/08 not met. This needs to be addressed as a matter of urgency. People’s wishes and feelings must be respected, including allowing them freedom of choice DS0000065154.V376812.R01.S.doc Timescale for action 31/08/09 2. YA6 15(1) 31/08/09 3. YA6 15(1)(2) 31/08/09 4. YA16 12(3) 31/08/09 Brookhaven Version 5.2 Page 30 5. YA19 15(1) and flexibility to change their minds, should they wish to do so. The health care needs of people living at the home must be recorded within the plan of care so that staff are provided with detailed guidance about how people’s needs are to be met. Timescale of 31/08/08 not met. The premises to be used as the care home must be kept in a good state of repair so that people living at the home are provided with a pleasant and safe environment in which to live. Timescale of 30/06/08 and 31/01/09 not fully met. Adequate furniture, bedding and other furnishings, including floor coverings must be provided in rooms occupied by residents so that they can live in a comfortable environment. Timescale of 30/06/08 and 31/01/09 not fully met. All parts of the home must be kept reasonably decorated, so that people living there are provided with pleasant surroundings in which to live. Timescale of 31/01/09 not met. 31/08/09 6. YA24 23(2)(b) 31/01/10 7. YA24 16(2)(c) 31/01/10 8. YA24 23(2)(d) 31/01/10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 31 No. 1. Refer to Standard YA2 Good Practice Recommendations When needs assessments have been conducted then this information should be retained on people’s care files so that staff are aware of individual assessed needs on admission to the home. The plans of care should include people’s strengths as well as their physical and mental conditions. People living at the home or their relative should be given the opportunity to be involved in the development of their own risk management framework, which should be recorded in the plan of care, so that they can decide what risks they wish to take within their daily life. Further improvements could be made so that everyone living at the home could be involved in some form of activity identified within their plan of care. The plans of care should show how people could be supported to maintain their leisure interests whilst living at the home. The care planning process should be extended to incorporate more details in relation to people’s abilities and independence. Any hand written transcriptions on the Medication Administration Records should be signed, witnessed and countersigned to avoid any transcription errors. The home should be upgraded and modernised throughout in order to provide a more pleasant environment and better facilities for the group of people living at Brookhaven. The training programme for staff should incorporate learning in relation to the specific needs of people living at the home, such as diabetes and schizophrenia. The monitoring of the quality of service provided should be further extended: By obtaining the views of people with an interest in the service; By implementing an annual development programme and By increasing the range of internal audits. 2. 3. YA7 YA9 4. YA12 5. 6. 7. YA16 YA20 YA24 8. 9. YA35 YA39 Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 32 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Brookhaven DS0000065154.V376812.R01.S.doc Version 5.2 Page 33 - 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!