Inspection on 10/10/07 for Brooklands 2

This inspection was carried out on 10th October 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Brooklands 2 11/04/07

Brooklands 2 24/10/06

Brooklands 2 03/11/05

Brooklands 2 20/07/05

Brooklands 2 17/03/05

Brooklands 2 06/10/04

Similar services:

Flint House

Hillview Farm

St Vincents

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

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

CARE HOMES FOR OLDER PEOPLE Brooklands 2 11 Old Parr Road Banbury Oxon OX16 5HT Lead Inspector Kate Harrison Unannounced Inspection 10th October 2007 10:30 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 Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 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. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brooklands 2 Address 11 Old Parr Road Banbury Oxon OX16 5HT 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) 01295 262083 01295 278404 mail@brooklandsnh.co.uk Brooklands 2 Ltd Mrs Doolyn Lacey Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th April 2007 Brief Description of the Service: Brooklands 2 is a three storey late Victorian town house situated in a residential road within easy access of Banbury town centre. The accommodation at Brooklands 2 is spread over three floors served by a passenger lift. The home’s accommodation is a mix of single and double rooms. There are three communal rooms on the ground floor, an assisted bathroom on each floor, and a small enclosed garden and patio area at the rear of the building. There is a registered nurse on duty at all times supported by a team of care staff, and the proprietors, Mark Taylor and Madeleine Taylor are usually available in the home. Fees range from £627.00 to £721.00 per week. There are additional charges for hairdressing, chiropody and personal items. Some additional charges may also be made for outings and to accompany people to hospital appointments. There are plans to significantly enlarge and improve the home in the near future. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10.30 and was in the service for 6 hours. This inspection was a thorough look at how well the service is doing. It took into account detailed information already provided by the service’s proprietor, and any information that we had received about the home since the last inspection. The inspector saw all areas of the home and looked at records and documents relating to the care of the residents. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that we sent out, and their views are included in this report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. From the evidence seen and from comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals with differing backgrounds, and with differing needs, such as religious, physical, or cultural needs. What the service does well: What has improved since the last inspection? The temporary arrangements, which were in place at the last inspection visit, are no longer in use, as the extra people accommodated due to building work have returned to Brooklands 1. This has meant that it is easier for the care staff to look after the individuals in the home. The personal and healthcare needs of individuals are met, and staff are better deployed to meet the needs of individuals. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 6 The staff training programme has continued, with input from a variety of sources. All staff who handle food have the necessary training, and the updated guidance regarding infection control is being implemented. Redecoration and refurbishment has continued in communal and private rooms. Plans are progressing to improve the environment of the home by adding an extension designed to better meet the needs of people living at the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 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 Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care; therefore Standard 6 was not assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals’ care needs are assessed before admission, to make sure that the home can meet the needs. EVIDENCE: The care needs of individuals are assessed before a place is offered at the home. Usually the registered manager or Madeleine Taylor, the proprietor, carries out the assessment, and usually visits the individual in hospital or at home. Information is also available from the care managers and from the hospital’s discharge summary, and relatives or representatives are invited to visit the home if the individual cannot come. Records of two individuals’ admission information show that a full assessment of need was carried out using the home’s forms, before the individuals were admitted to the home, and that subsequently the home is able to meet their needs. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals living at the home receive the healthcare and personal care they need, in a caring and respectful way. EVIDENCE: The personal healthcare needs of individuals living at the home are recorded in each person’s care file. Risk assessments are completed for healthcare issues such as moving and handling individuals, falling and nutrition, and action is taken to minimise risks. The ‘Summary of Need’ in each file provides a comprehensive overview of the individual’s care needs, and the ‘About Me’ booklet gives the individual and relatives an opportunity to record the life story of the individual. Life story information is used to offer appropriate activities and conversation topics for staff to engage with the individual. The registered manager is looking to make the care plans more person centred, so that the individual’s view of care is taken more into account. Staff members treat people respectfully, and personal care is delivered in private. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 10 People living at the home receive the healthcare they need. Comments from our survey show that the majority of respondents say they ‘always’ get the healthcare they need. Relatives said during the inspection visit that the personal care is ‘very good’, and that staff members are ‘very good’, and the records show that healthcare professionals are involved as necessary in the care of the people living at the home. There are good systems in place to make sure that the home’s medication is recorded, administered and disposed of appropriately. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home are supported to be independent and to keep contact with friends and family. EVIDENCE: The home has an activity plan and care plans show what activities are preferred and enjoyed by individuals. There is a mixture of group and individual activities, though some individuals prefer not to take part in any activity. The majority of people living in the home who responded to our questionnaire said that there was ‘always’ activities arranged that they could take part in. One individual is encouraged to continue playing the home’s piano, and clearly enjoys the activity. Staff members make sure that individuals have choice over their daily routines, for instances, in choosing what to wear. The home has three downstairs communal rooms, and people living at the home use all the rooms to eat at lunchtime. People mainly eat from trays on individual tables, though a few eat at the dining room table. It is recommended that individuals be encouraged to use the dining room, so that individuals are presented with more opportunities to socialise and mobilise, and lunchtime becomes more of a social occasion than at present. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 12 Door guards are used as part of the risk assessments to help keep two individuals safe at night, and the risk assessments have been appropriately drawn up with input from other healthcare professionals. It is recommended, as it is not clear that staff members always remove them to comply with the safety risk assessment, that care plans are amended to include door guard removal times. It is also recommended that training about the Mental Capacity Act 2005 be cascaded to all care staff members, so that they fully understand the implications of the Act. Several visitors on the day of the inspection visit said that they feel welcome at the home, and they are known to staff members and can discuss any issues with staff when they visit. The home’s menu shows that individuals have a choice to the main dish, and there is a good system in place to record food preferences. However some individuals in response to our survey said that their preferences were not taken on board. ‘They keep giving me food I don’t like’ was one comment, and ‘they don’t seem to take any notice of what I like and don’t like’ was another. The registered manager should make sure that people are offered meals they prefer, so that individuals feel respected. Other individuals said that the food is good and one relative said that there is ‘always lots of it’. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are safeguarded from harm and have their concerns and complaints heard. EVIDENCE: The home’s complaints procedure is accessible and several relatives said that they knew what to do if they needed to complain on behalf of their relatives. Some said that any concerns were addressed quickly, and that they had confidence in the registered manager who made herself available to relatives and visitors. On the day of the inspection visit some visitors spoke to the registered manager and reported that she had followed up issues promptly. In a telephone conversation one relative said that issues brought to the proprietors were not always thoroughly addressed, and this issue has been relayed to the proprietors. Three complaints were recorded since the last inspection, and the complaints procedure was followed in responding to them. We have received information concerning one complaint made against the service since the last inspection and this issue is not yet concluded. The home has a safeguarding policy in line with the local multi-agency codes of practice, and no referrals have been necessary since the last inspection. Staff members receive initial training on how to safeguard the people living in the home during induction training and follow-up training has been provided during 2007. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The planned development of the home will improve the environment for the individuals who live there. EVIDENCE: The home is an Edwardian town house, and has some of the rooms on the upper floors can be isolated at times because of the nature of the building. The home’s development plan includes a major expansion to the home in the next year, and will include more communal space, three gardens and a circular internal walkway. These improvements should mean that the quality of life would improve for the people living at the home. The plans also include a new kitchen and laundry room. The laundry room is cramped and difficult for staff to work in at present. Two members of staff share the house maintenance routine, and a system is in place to make sure that repairs are carried out quickly. Several bedrooms have recently been redecorated, and refurbishment of the home is continuing Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 15 while awaiting the development of the home. The home was clean and fresh at the time of the inspection visit. The home’s infection control policies have been updated and three of the home’s nurses recently attended infection control training. The registered manager confirmed that individual hoist slings are available for those needing assistance with moving. The environmental health officer has recently visited and the recommendations made have been implemented. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Enough safe, caring staff look after the people living at the home. EVIDENCE: The home’s staff rota shows that a mix of nurses and carers are available to meet the needs of the people living at the home over the 24 hours, and the registered manager confirmed that there are enough staff members on each shift to meet the needs of the individuals. Relatives said that the majority of staff members were kind and thoughtful. Two comments were received about the quality of English spoken by some care staff, and the proprietors have organised English language classes to help care staff improve their conversational English. At the last inspection visit the home was meeting the National Minimum Standard of 50 care staff with National Vocational Qualification (NVQ) Level 2 in Care. Due to staff turnover and difficulties about time in country restrictions for overseas staff members wanting to start NVQ training, at present the home is not meeting this standard, but is working towards it. The home has an induction programme to the appropriate standard, and a training programme and training updates programme for nurses and carers. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 17 Several of the senior carers qualified as nurses overseas, and are undertaking the Overseas Nurses Programme, to qualify as nurses in this country, and this includes update training. There is a system for nurses to be responsible for cascading key messages from training courses to carers, so that all care staff are aware of new procedures. The home’s recruitment procedures are robust and now include a record of the date when the clearance email regarding the Criminal Records Bureau was received. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team have made improvements to the home to reflect the views and best interests of the people who live there (and their representatives). EVIDENCE: The registered manager has been in post at the home for several years and has enrolled on the Registered Manager’s Award NVQ Level 4 programme. Relatives said how she makes herself available for them and for individuals living at the home, so that she is aware of any issues arising and can take action to address any issues. The proprietors are available in the home on a daily basis to support the registered manager, and are aware of the current developments and pressures in social care. The development of the home is planned to improve daily life for the people living there. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 19 The proprietors consult regularly with people living at the home and with others such as relatives and staff. An annual quality assurance survey was carried out earlier this year, and relatives and staff meetings are held to hear views and to share information. No monies are managed on behalf of people living at the home, and all costs incurred on their behalf are invoiced. The home has a health and safety policy and one of the proprietors is responsible for health and safety at the home. There is a fire risk assessment in place, and measures are in place to protect people in the event of a fire at the home. Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP14 Good Practice Recommendations It is recommended that the care plans regarding night safety and door guards be amended, to include door guard removal times, so that staff members remove the guards appropriately. It is recommended that training about the Mental Capacity Act 2005 be cascaded to all care staff members, so that they fully understand the implications of the Act. It is recommended that individuals be encouraged to use the dining room, so that individuals are presented with more opportunities to socialise and mobilise. The registered manager should make sure that people are offered meals they prefer, so that individuals feel respected. 2 3 4 OP14 OP15 OP15 Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Brooklands 2 DS0000046642.V339287.R01.S.doc Version 5.2 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!