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Inspection on 15/12/05 for Brooklands Care Home

Also see our care home review for Brooklands Care Home for more information

This inspection was carried out on 15th December 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents are well protected by the home`s medication administration systems and practices. The residents have the benefit of a home that is run in their best interests by a qualified and capable Manager. They are protected from financial abuse by robust systems of finance management.

What has improved since the last inspection?

Residents now have the benefit of improved care planning documentation.

What the care home could do better:

The service could employ more staff with an NVQ level 2 qualification. It could also request of the supplying pharmacist, that all security seals on the Nomad medication administration system, be used.

CARE HOMES FOR OLDER PEOPLE Brooklands Care Home Springfield Road Grimsby North East Lincs DN33 3LE Lead Inspector Janet Lamb Unannounced Inspection 15th December 2005 09:30 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 Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brooklands Care Home Address Springfield Road Grimsby North East Lincs DN33 3LE 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) 01472 753108 01472 278023 Southern Cross Home Properties Limited Mrs Dorothy Marfleet Care Home 63 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (31), of places Physical disability (11) Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Three Physically Disabled service users to be accommodated in the main part of building until such time as a vacancy occurs in the designated unit. The Maximum number of service users to be accommodated in the home with a physical disability will remain at 11, and shall not be increased again. A new admission into any one of the three places in the main building shall not take place automatically, but only with the approval of the CSCI 28th July 2005 Date of last inspection Brief Description of the Service: Brooklands is a purpose built care home in a residential area of Grimsby, providing nursing to a maximum of 63 service users. The home has two floors and rooms are all single. There are satisfactory communal facilities, a rear garden area and a passenger lift. Local facilities are within walking distance and the centre of Grimsby is only a bus ride away. Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Broolands Care Centre, the second of two to be carried out in each inspection year, took approximately six hours to complete. The inspection involved an interview with the Manager and two residents, discussion with the homes’ Administrator and three staff, viewing of some of the records and documents and a brief tour of the property. What the service does well: What has improved since the last inspection? 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. Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 6 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 Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 7 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): These standards were not assessed at this inspection. EVIDENCE: Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 8 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): 9 only. Residents are satisfactorily protected by the home’s medication administration systems. EVIDENCE: Residents spoken to expressed complete satisfaction with the systems within the home for administering their medication. Although some are capable of self-medicating, residents feel it is not appropriate for them to do so, and clearly relinquished any responsibility to. Systems within the home follow policies and procedures and only staff trained to administer medication do so. The medication administration trail is robust and protects residents. Nomad monitored dosage system is in use, but the supplying pharmacist is not applying all three security/safety seals available to the system. The Manager should approach the supplying pharmacist and request the Nomad system be supplied in its proper and intended form. Staff that administer drugs are aware of their responsibilities and know they must exercise caution and accuracy. Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 9 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): These standards were not assessed at this inspection. EVIDENCE: Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 10 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): These standards were not assessed at this inspection. EVIDENCE: Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 11 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): These standards were not assessed at this inspection. EVIDENCE: Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 12 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 only. Residents are in fairly safe hands at the moment, but this could be improved with an increase in deployed staff holding NVQ qualifications. EVIDENCE: The staffing team consists of a Registered Manager, two senior nurses and four nurses, four senior carers of whom two have NVQ level 3 and one has level 2. There are 32 carers of whom eleven have or are doing NVQ level 2. There is one administrator, two team leaders and twelve ancillary staff. Of the 38 care staff, 16 have or are completing the appropriate NVQ training, but the home is still not meeting the requirement to have 50 of its care staff with the award. Trained nursing staff undertake periodic training and practice to maintain their Nursing and Midwifery Council personal identification number. It is acknowledged that staff turnover amongst a large number of employees can be disruptive. A comprehensive list of corporate training has been supplied showing courses and venues from July 2005 to January 2006. Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 13 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): 31, 33 and 35. Residents benefit from a fairly well run home that is run in their best interests, and they have their financial interests fairly well protected. EVIDENCE: Residents spoken to were fully aware of the position and qualification of the Registered Manager, and expressed confidence in her and the staff team. Residents realise the home is run in their best interests, but were of the opinion that they could not influence issues too much and that this was rightly so. Discussion was held with one resident about choosing the decoration in her room, but she felt it was not her place to say what this should be. The management and staffing team has replaced residents’ care plan documents with a new format, which meets the new company expectations and which is an improvement. Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 14 Residents spoken to acknowledged the lack of control they have over their personal finances, but this was due to the fact that they had passed responsibility over to family or solicitor. On the whole they are satisfied with the allowances they have and with the way in which their affairs are handled. The administrator explained about how finances are handled in the home and showed one resident’s details on the computer system. Audit checks are undertaken, individual statements can be obtained, and all records and receipts are kept separately for each resident. Systems are satisfactory. Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 15 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 16 No. 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 OP28 Regulation 18 and 19 Requirement The Registered Provider must ensure 50 of care staff achieves NVQ level 2 by the end of 2005. Timescale for action 31/01/06 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 Refer to Standard OP9 Good Practice Recommendations The Registered Manager should liaise with the supplying pharmacist to request s/he uses all three security seals on the Nomad medication administration system. Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Brooklands Care Home DS0000002776.V273299.R01.S.doc Version 5.0 Page 18 - 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. 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