Inspection on 31/01/07 for Brooklands

This inspection was carried out on 31st January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brooklands 31/03/09

Brooklands 31/12/05

Brooklands 31/05/05

Brooklands 10/03/05

Brooklands 03/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Brooklands 25 Lambeth Road Eastwood Leigh On Sea Essex SS9 5XR Lead Inspector Helen Laker Unannounced Inspection 31st January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brooklands DS0000015524.V319318.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 DS0000015524.V319318.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brooklands Address 25 Lambeth Road Eastwood Leigh On Sea Essex SS9 5XR 01702 525375 01702 421121 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) Dr Ram Kishore Tandon Miss Bindu Varghese Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (44), Physical disability (1) of places Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of service users for whom nursing and personal care is to be provided shall not exceed 45. Nursing and personal care may be provided to no more than 44 older people over the age of 65. Nursing care may be provided to no more than one service user with a physical disability who may be above the age of 50 years. 20th December 2005 Date of last inspection Brief Description of the Service: Brooklands is a large detached establishment set within its own well maintained grounds in the Eastwood area of Leigh on Sea. The home is close in proximity to all community amenities and services. Brooklands is decorated, furnished and maintained to a good standard throughout. The home has carparking facilities to the front and rear of the property. Brooklands is a care home with nursing providing 29 single bedrooms and 8 shared bedrooms. The home provides nursing care for 44 Older People and one Physical Disability service user. Residents are accommodated on two floors that are serviced by a passenger shaft lift. The Service User Guide and Statement of Purpose are available and are updated as required. The residents and their representatives are provided with this information and also the manager was informed that latest Commission for Social Care Inspection reports must also be available. At the time of this report the manager confirmed that the fees ranged from £369.00 to £682.00 per week and a completed pre inspection questionnaire was provided. Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection, which took place over one day with one inspector in the home. There was a tour of the premises and grounds and an inspection of records and documentation. Time was spent discussing the care of the service users. The proprietor and manager in charge of the day to day management of the home and they were spoken with. Further feedback was also received from service users and care staff through survey and discussion. Responses have been included in the relevant sections of the report. A pre-inspection questionnaire and other reports and correspondence provided by the staff on duty were also used as evidence to inform this report. Twenty two National Minimum Standards were inspected on this occasion, nineteen overall outcomes were met and there are two requirements and one recommendation detailed in this inspection report. Discussion of the inspection findings took place with the proprietor and manager in charge of the day to day management of the home and the deputy manager at the end and throughout the inspection and guidance was given. Key standards as identified in the intended outcomes sections of this report are inspected at least once every twelve months during a key inspection. What the service does well: What has improved since the last inspection? There is clear guidance and direction to staff and the home does overall have in place practices that will promote and safeguard the health, safety and welfare of the people using the service. Official staff supervision has commenced involving delegation of supervisor roles to senior staff, and staff morale is now much improved. Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brooklands DS0000015524.V319318.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 DS0000015524.V319318.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&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their supporters have adequate information about the home so that they can make informed choices. The admission procedure generally does include an adequate assessment, which ensures that service users needs can be met. The home provides a caring environment where visitors are made welcome. EVIDENCE: Care records generally evidenced a full assessment had been undertaken by the manager or senior staff. Full social worker assessments were available for those residents sponsored by local authorities. Pre admission assessments were reviewed for the homes most recent admissions. Attention should be paid to visiting any new service users prior to admission, dating and signing documentation and any assessments at the time of completion to ensure accurate information is maintained. Wherever possible it is advised that residents or their relatives are involved in the assessment Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 9 process. All prospective residents and their families are invited to visit the home before making a decision. Brooklands does not provide intermediate care. Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 10 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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has an individual plan and service users are generally supported to take risks as part of an independent lifestyle via a process of assessment. The health needs of service users are met, and documentation does ensure clarity of needs. Medication procedures are followed appropriately. Personal support is overall provided in a way that promotes dignity. EVIDENCE: Examination of a random sample of residents care plans evidenced an admission care plan and a comprehensive care plan developed during the trial period. Care plans seen were to a good standard, clearly identifying residents needs and giving concise instructions to staff on how those needs should be met. There was evidence of service user and family involvement. No resident has been assessed as able to manage his or her own medication. All medication is administered by nursing staff. Records were completed Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 11 appropriately. Records showed good monitoring of health needs and appropriate referrals to medical professionals. Residents were complimentary with regards to the way their personal and health care needs were being met and felt that staff treated them in an appropriate way, respecting their privacy and dignity. One incident regarding a service users privacy was highlighted on the day of inspection and dealt with by the manager. Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 12 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, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home can provide a range of meaningful pastimes, documentation of these needs to be developed to promote the residents mental and physical wellbeing. Links with families are good and contacts are maintained. Choice in the routine of the day is adapted to ensure resident’s rights are maintained. The home provides good food in ample quantities and is served in a congenial setting. EVIDENCE: The home has an activities organiser who covers 24 hours a week and arranges a wide range of activities for the residents both in groups and individually including activities which take the residents outside the home. She previously said she hopes to develop a mobile shop for residents to purchase small items including toiletries and sweets. This has been done. Residents meetings allow residents to express their opinion on the home’s menus, quality of food, activities and on the general running of the home. Residents were generally satisfied with the level of activities and said they can say what they like at the residents meetings. Documentation regarding activities should be more ordered and consistent. Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 13 Visiting relatives said they were always made welcome and can visit when they liked. One relative commented that she was very impressed with the home. The home’s menus were seen to contain a wide range of varied and nourishing meals. Nutritional records kept highlighted some gaps and new menus developed for table display were seen. Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 14 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints policy, which informs complainants of their rights, in the event of any informal or formal complaint documentation must be maintained appropriately and fully. Staff receive relevant training relating to the protection of vulnerable adults but this must be updated regularly. EVIDENCE: The home has an appropriate complaints policy and procedure. No complaints had been received since the previous inspection. The recording of informal complaints was also discussed at this inspection with the manager. Appropriate policies and procedures are in place for the Protection of Vulnerable Adults. Most staff have now received Protection of Vulnerable Adults training. Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 15 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to provide a good standard of accommodation for the residents. EVIDENCE: Although there is still no plan of renewal of fabric and decoration, the proprietor informed the inspector that bedrooms are redecorated with every change of occupancy and if anything goes wrong he repairs or replaces it immediately. All bedrooms seen were well furnished and decorated and personalised to each individual service users taste. A plan of renewal of fabric and decoration was discussed with the proprietor at the last inspection. The home has sufficient aids and adaptations and has been assessed by an occupational therapist and was found to be suitable for service users. The home was clean and tidy throughout with no odours present. The home benefits from a large well-equipped laundry. Brooklands DS0000015524.V319318.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels are currently maintained to meet the needs of service users. Recruitment practices demonstrate robust recruitment procedures. Staff training is addressed but more prominence should be paid to appropriate updates being undertaken to provide a competent work force and it being in line with TOPPS. EVIDENCE: Staff rotas indicated that agreed staffing levels are maintained. Staff on duty during the inspection matched those stated on the duty rota. Staff records were examined during a visit to the home on the 20th December 2005. These were found to contain all the information required to meet this standard. The same was evident at this inspection with the recruitment records sampled. Staff induction programme is still not to TOPSS specification. A wide range of training is available to staff, however, a programme needs to be developed to ensure all staff receive training and refresher courses at the appropriate times Staff are now receiving supervision on a regular planned basis. Service users said,” the staff are lovely and caring although at times they are very busy”. Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is guidance and direction to staff and the home does overall have in place practices that will promote and safeguard the health, safety and welfare of the people using the service. Attention is still required with regard to legislative monitoring and audit within the home. EVIDENCE: The current manager is currently undertaking her Registered managers Award in order to meet to meet NVQ level 4 in management and care requirements. She has recently married and will be contacting the CSCI with a view to updating documentation with her married name. At a previous inspection a member of staff who had worked in the home for a number of years felt that the new manager was “the best thing that had happened to the home”. Staff said “she was easy, approachable and they had confidence in her.” Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 18 The home does not have an official quality assurance scheme, however Regulation 26 visits are being carried out by the proprietor, these have not been consistent and the proprietor was again reminded regarding this. The manager has produced service users, staff and family quality questionnaires. Discussions took place regarding further action required to meet this standard. The home has appropriate insurance policies. A current employer liability certificate was displayed. It is judged that procedures are in place to ensure appropriate management of the business and there is no evidence to suggest that the home is not financially viable. The home looks after small amounts of resident’s personal money for day to day expenses e.g. Hairdresser, chiropody etc. A random sample of money and records checked at this inspection were seen to balance. Staff supervision has commenced but are still incomplete. The manager showed the inspector a delegation plan, delegating care staff supervision to the Registered Nurses. All staff spoken with were generally knowledgeable of service users needs and all have received recognised training over the years. However, there is a need to provide an organised programme to ensure all staff receive training and refresher courses at the appropriate time. Records seen throughout the inspection were generally well maintained, accessible and securely stored. Some records have been commented on throughout the report. Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP30 Regulation 12 & 18 Requirement The registered person must ensure that all staff employed at the home receive training for the work undertaken. It is recommended this meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfils the aims of the home and meet the changing needs of service users. Timescale for action 02/04/07 2. OP33 Reg 26 The Registered Provider must 02/04/07 ensure that effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure the success in meeting the aims and objectives and the Statement of Purpose of the home. Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations It is recommended that activities be developed and recorded in a more ordered manner and that service users care plans reflect this. Brooklands DS0000015524.V319318.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 DS0000015524.V319318.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!