Inspection on 06/02/06 for Brookholme Croft Nursing Home

This inspection was carried out on 6th February 2006.

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

Brookholme Croft Nursing Home 22/10/08

Brookholme Croft Nursing Home 09/08/07

Brookholme Croft Nursing Home 21/06/06

Brookholme Croft Nursing Home 25/01/05

Brookholme Croft Nursing Home 30/06/04

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 Brookholme Croft Nursing Home Off Challands Way Hasland Chesterfield Derbyshire S41 0EU Lead Inspector Angela Kennedy Unannounced Inspection 10:00 6 February 2006 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 Brookholme Croft Nursing Home DS0000002045.V271891.R02.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. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brookholme Croft Nursing Home Address Off Challands Way Hasland Chesterfield Derbyshire S41 0EU 01246 230006 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) morverndax@aol.com Dr A P M Matthews Mrs A Matthews Angela Alice McInnes Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 2005 Brief Description of the Service: Brookeholme Croft is a purpose built care home, which opened in 1996. The home provides nursing and personal care and support for up to 40 older persons. The home is located within the village of Hasland, within close proximity of Chesterfield town centre. The home is situated at the head of a residential close, and provides level access to a well-kept garden to the rear of the building. There are also car parking spaces to the front of the home. The home provides single room accommodation for all residents; nine rooms have en-suite toilet and wash hand basin facilities. There is an option for those who choose to share a room, as there are two sets of rooms which link via interconnecting doors. These doors are kept locked when the rooms are used as single accommodation. There is a choice of shared bathrooms and toilets, which are suitably located and equipped. The registered manager is a registered general nurse, who is supported by a team of nursing, care and hotel service staff. The home’s stated aims are to provide a friendly, safe and pleasant environment, together with high standards of care and support, delivered by a dedicated and professional staff team, who will promote individual’s rights to privacy, dignity and choice. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over approximately 5 hours and was unannounced. The manager of the home was available throughout the inspection. During the inspection a tour of the building was undertaken. Several documents were examined, including three residents’ files (this is part of the case tracking process, that helps to determine that residents needs are being met). Three members of the staff team were interviewed and several residents. Two residents were spoken with at some length. An assessment of the requirements left at the last inspection was undertaken. What the service does well: What has improved since the last inspection? It was apparent that the manager had made positive steps to meet with the requirements made at the last inspection; Individual needs assessments have greatly improved in the resident’s files examined. The menus had been revised and now run over a 5-week period rather than a 3-week period therefore offering more variety and choices in meals. One resident spoken with stated that following a request made during a residents meeting additional choices were now given at breakfast time. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 6 Residents who are able had been consulted regarding their care plans, this was confirmed by the manager of the home and was seen within one residents file examined. Some of the residents spoken with confirmed that they had been consulted regarding their plan of care. The home has now produced a leaflet for residents, which explains the home philosophy of care. The manager stated that this is available to all new residents and residents living at the home. The manager has now produced an audit document that reviews and checks that all areas of care, management and health and safety within the home are undertaken. This in itself provides a useful and clear document that demonstrates that the practices of the home are being undertaken, to ensure that a good continuity of care and safe working practices are maintained. What they could do better: On discussion with the manager and from reading documentation it was apparent that some of the requirements left at the last inspection had not been fully understood: A requirement from the last inspection was that an annual development plan should be in place for the home. The manager has produced an audit document (see above) Once information is gathered from the audit document and through consultation with the residents, an annual development plan for the home can be produced, which will further demonstrate that the home is run in the best interests of the residents. A requirement from the last inspection was that a written policy must be developed in relation to residents self administering their medication. A written policy is available within the home but requires further development to include a criteria for staff to use, in relation to the assessment of an individual to determine their ability to self medicate. Staff supervision is undertaken within the home; this was confirmed by both the manager and the staff spoken with. However written evidence must be in place to support this. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 7 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. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 8 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 Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 9 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): 3 Residents needs were generally well met, however the homes registration category requires amendment to include all the residents living at the home. EVIDENCE: Of the residents files examined all demonstrated that the residents needs had been assessed and care plans were in place to support their assessed needs. Two residents spoken with were positive regarding the care provided by the staff team. One resident living at the home had been admitted for dementia care. Although it was apparent from training records seen, and through staff discussion that the relevant skills and qualifications to care for this individual were in place the home is not registered to provide dementia care. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 10 Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 11 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): 7.9 Most aspects of resident’s health, social and personal care needs were met, however these require further development. EVIDENCE: Of the records seen regarding individual residents care it was demonstrated that their health and personal care needs were being met. Discussions with residents indicated that some staff on occasion were not always as respectful to the residents wishes or requests as they could be. However the general feedback from the residents spoken with was positive regarding the care provided by staff at the home. Discussions with staff demonstrated that staff were conversant with the residents needs and had undertaken the required training to enable them to meet the needs of the residents. The written policy within the home in regard to residents self administering their medication did not include a criteria for staff to use, in relation to the assessment of an individual to determine their ability to self medicate. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 12 The manager confirmed that at the present time there were no residents who were able to self medicate. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Although resident’s needs are generally well met, further development of social activities would benefit the resident group, as would the consideration in the provision of alternative meal choices. EVIDENCE: Discussions took place with some residents regarding the types of activities that were provided at the home. All of the residents spoken with expressed an interest in the activities provided and appeared to welcome them. Comments from residents regarding the activities within the home were very positive. One residents spoken with talked about the trips out that had been arranged by the home in the past and how enjoyable they had been. This resident said that regular trips out to the local community would be nice, such as the town centre to look around the shops and have a coffee. Residents were able to maintain links with their families and friends and stated that all the residents living at the home-received visitors, the residents spoken with confirmed this. One resident talked about the Christmas party, which was provided by her previous employers and how she had enjoyed this. The homes activity coordinator, who worked at the home four half days a week was spoken with regarding the activities that were provided within the home. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 14 This included, craftwork, which was often seasonal crafts, an example of this was Christmas cards that had been made by residents and then sold to family and friends of the home. The residents were at present in the process of designing Easter bonnets. Other activities provided were carpet bowls, seat exercises, music and movement, quizzes, bingo and reminiscing discussions. The activity coordinator said that the female residents also enjoyed beauty therapy such as a manicure and a hairdresser visited the home on a weekly basis and has use of the homes salon, from discussions the hairdresser seemed popular with both the female and male residents. The activities coordinator confirmed that trips out were organised for the residents and entertainers regularly visited the home. A brochure has been designed by the home for residents, this was seen and was robust in detail and included information on activities, visiting and meals/ mealtimes and stated that residents are able to personalise their own private accommodation. It was noted that many residents had chosen to do this as many rooms seen reflected the resident’s own taste and lifestyle. The brochure also stated that residents were able to access their own care file at any time. The manager confirmed that resident’s religious and cultural needs were met as required. This included visits from the local Baptist church once a month were a service was provided and all residents were able to join in as they wished. One resident continues to attend their local church, and the manager stated that if a resident wished to be visited by their own minister this would be arranged. A requirement from the last inspection was that the resident’s individual choice was actively and routinely promoted, this was in part with regard to meal choices offered. It was noted at the last inspection that an alternative was offered to the main course but on occasion the alternative was the same food offered in a different way. Although the menus had been revised, and now run over a 5-week period rather than a 3-week period therefore offering more variety and choices in meals it was again noted that one of the alternative meals on the menu was the same food presented in a different way, for example roast chicken dinner or chicken sandwich. The manager confirmed that if a resident did not like chicken then an alternative would be provided. However this situation could be avoided with careful meal planning. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The homes complaints procedure and practices demonstrates that complaints are taken seriously and acted upon promptly. Robust procedures are in place to protect residents from abuse. EVIDENCE: The homes complaints policy and procedure was seen and found to be satisfactory in detail and included information on how to make or refer a complaint to the CSCI any stage. The homes complaints log, which records all complaints and actions taken, was also seen; records examined were clearly documented and dealt with appropriately within the required timescales. Residents spoken with confirmed that they were aware of the complaints procedure and stated that they would report any concerns they had to the manager of the home or to their relatives. Of the residents spoken all confirmed that the manager dealt with any concerns or issues promptly. The homes adult protection policies were examined and found to be satisfactory. Of the staff files seen adult protection training had been undertaken and staff confirmed their understanding and awareness within this area. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 16 The resident’s monies were kept by the home within a lockable safe. The manager confirmed that some residents kept a small amount of money within their private accommodation. (Please see standard 35 for further information) Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 17 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): EVIDENCE: Standards 19-26 were not assessed at this inspection. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 18 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): 28,29,30 Residents are protected by the homes recruitment practices and their needs are supported by a competent staff team. EVIDENCE: 24 care staff are employed at the home, 7 care staff have achieved an National Vocational Qualification (NVQ) in care at level 2 and 8 care staff are undertaking NVQ2 in care at the present time. This demonstrates that the home is committed in ensuring that national targets for NVQ’S are met Two care staff were interviewed on the day of inspection, both had achieved an NVQ2 in care and one had also achieved an NVQ3 in care, although it was stated that NVQ3 had been undertaken at the local college, as funding was not available within the home for this training. Of the staff files examined the following documentation was seen: Recruitment records were in place and found to be robust in detail and included a satisfactory application form, interview records, proof of identity, criminal records bureau checks, 2 written references and terms and conditions of employment. Induction training was recorded and had been undertaken within the first 6 weeks of employment, this training had included a training and development programme, which meets the required standard. Foundation training was recorded and had been undertaken within the first six months of employment as required. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 19 Positive comments regarding the induction and foundation training provided by the home was given by the staff spoken with. This demonstrates that the home endeavours to meet the assessed needs of their residents by ensuring that staff are equipped to meet those needs, through the correct training and development programmes. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 20 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): 33,35,36,38 The home strives to encourage residents to make choices regarding their lives, however a more structured and organised approach needs to be implemented to ensure residents views are regularly sought. Resident’s financial interests and health and safety are safeguarded by the homes practices. Staff supervision requires further development. EVIDENCE: The manager stated that residents meetings were usually held once every three months, but had not been held recently due to workload. Residents spoken with confirmed that residents meeting were held and were found to be very useful in allowing them to express their views and opinions. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 21 Comments made under standards 12 – 15 also apply here in relation to the promotion of residents’ interests. A requirement from the last inspection was that an annual development plan should be in place for the home. The manager has produced an audit document. Once information is gathered from the audit document and through consultation with the residents, an annual development plan for the home can be produced, which will further demonstrate that the home is run in the best interests of the residents. The resident’s monies were kept by the home within a lockable safe. The manager confirmed that some residents kept a small amount of money within their private accommodation. The resident’s financial transaction records were examined and found to be satisfactory. The transaction sheets were audited by the manager on a monthly basis, which demonstrates that the home endeavours to safeguard the financial interests of the residents. It was confirmed by the manager that the home does not act as an appointee for any residents’ monies. An inventory sheet of residents’ belongings, such as items of furniture was found within the residents files seen, however not all inventory’s seen had been completed. Residents spoken with confirmed that they were happy with the arrangements regarding the safe keeping of their monies. The staff that were spoken with and the manager confirmed that staff supervision was undertaken within the home; however the written evidence available within the files indicated that staff supervision had not taken place since 2004. Written evidence should be in place to support that staff supervision has taken place. Some of the policies and procedures of the home that promote safe working practice were examined and were detailed in content. Maintenance certificates for the home were examined and found to be up to date, this included maintenance of fire extinguishers. Staff had received up to date instruction in understanding and implementation of the homes fire procedure. The home at present has three trained first aiders, the manager confirmed that this training was due, along with food hygiene training. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 22 Risk assessment were in place for all areas of the home, these were seen and found to be satisfactory. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 X 3 Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 24 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 3 Regulation Part2,28 (1)CSA 2000 Requirement Timescale for action 01/03/06 2 9 13 (2), (4) (b) (c) 3 12 12 (2) (3) 4 15 12 (2), 16 (i) Residents admitted into the home must be in accordance with the homes category of registration identified on the registration certificate. The registered person must submit a variation application for those identified residents whose admission lies outside the homes registration category. A written policy must be further 30/03/06 developed in relation to the selfadministration of medicines, with documented risk assessments in place for residents who wish to retain or self-administer their medication. The registered manager must as 30/05/06 far as is practicable ascertain and take into account residents wishes and feelings, and to enable residents to make decisions regarding their life styles individual choice should be actively and routinely promoted. Consideration to the alternative 30/05/06 choice on menus should be given to ensure a varied choice of meals are offered. DS0000002045.V271891.R02.S.doc Version 5.0 Brookholme Croft Nursing Home Page 25 5 33 24 (1) (2) 6 36 18 The registered manager must ensure that there is an annual development plan in place for the home, that provides for the continuous review of the quality of care and services offered by the home, including nursing care. (Previous timescales given: 01.09.04/31.03.04) Staff must receive appropriate supervision. 31/03/06 01/04/06 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 35 33 36 Good Practice Recommendations An inventory of resident’s property should be kept within the home/residents personal file. The registered manager should develop consultative methods and practices in order to empower service users. Staff should receive formal supervision at least 6 times a year. Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 26 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 Brookholme Croft Nursing Home DS0000002045.V271891.R02.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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