Inspection on 10/10/05 for Brooklands House

This inspection was carried out on 10th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 House 11/11/08

Brooklands House 30/07/07

Brooklands House 24/04/06

Brooklands House 24/05/05

Brooklands House 18/10/04

Brooklands House 13/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Brooklands House 3 Woodville Terrace Lytham St Annes Lancashire FY8 5QB Lead Inspector Denise Upton Unannounced Inspection 10th October 2005 09:00 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 House DS0000009800.V256980.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 House DS0000009800.V256980.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brooklands House Address 3 Woodville Terrace Lytham St Annes Lancashire FY8 5QB 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) 01253 736393 Mrs Carol Josephine Gilligan Mr Patrick Joseph Gilligan Mrs Carol Josephine Gilligan Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 25 service users in the category of OP (Older Persons over the age of 65 years). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 24th May 2005 Date of last inspection Brief Description of the Service: Brooklands House is situated in a quiet residential area of Lytham but in close proximity to Lowther Gardens, the promenade, the main shopping area of the town and community facilities and resources. The home is arranged over two floors with the majority of service users accommodated in single bedroom accommodation. Only one bedroom is for shared occupancy. The home is registered to accommodate up to 25 older people who do not require nursing care. Mr and Mrs Gilligan are the registered providers and a manager has been appointed although this person is not currently registered with the Commission For Social Care Inspection. At this present time, Mrs Gilligan oversees the running of the home and directs all professional issues and care practices. Training is viewed as a positive tool to improve standards and to provide a high quality service. All staff are expected to undertake relevant training including nationally recognised N.V.Q. training and become accredited to a minimum of Level 2. Personal care is provided as required and specialised needs can be catered for. Any nursing needs are referred to the community district nursing team. In house activities are arranged and service users can choose whether to participate or not. Visitors are welcome at any time of the service users choice and can be entertained in the privacy of the residents individual bedroom accommodation or any communal area of the home. Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection began at 9.00am and in total spanned a period of almost nine hours. The inspector spoke with homeowner, the home’s manager and two of the care staff that were on duty during the course of the visit. In addition, four of the 20 residents ‘at home’ at the time of the inspection were spoken with individually either in the lounge area of the home or in individual bedroom accommodation. Several other residents were also collectively spoken with informally during the course of the inspection. In addition, a relative of a resident who was visiting the home was also spoken with individually. During the course of the inspection, one relative also completed a The Commission For Social Care Inspection relative/visitors comment card. This provided further information on how this particular relative felt that Brooklands House Care Home was meeting the needs and requirements of people who live at the home. A number of records and policies and procedures were also examined and a partial tour of the building took place that included communal areas and some bedroom accommodation. The majority of the core standards regarding Care Homes for Older People had been assessed at the last inspection that took place in May 2005. The outstanding seven core standards were assessed at this inspection along with a reassessment of the requirement and recommendations identified at the last inspection. What the service does well: Brooklands House has a group of staff that work well together and who display a good understanding of the care needs of residents and are keen to provide a quality service to people who live at the home. A number of residents spoken with stated that they felt they were well looked after and that they safe and secure living at the home. Residents are encouraged to maintain contact with their family and friends and visitors are made welcome at any time of the resident’s choice. Visitors can be entertained in individual bedroom accommodation or any communal area of the home. The relative of a resident spoken with said that there is good liaison from the home and she is always kept well informed of her father’s situation. The dietary needs of residents are well catered for with menus designed around the likes and dislikes of residents accommodated. A choice of menu is offered and the majority of residents spoke highly of the meals served. Like Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 6 wise, the communal and individual bedroom accommodation is comfortable and residents are encouraged to maintain control of their own financial affairs and exercise choice over all aspects of their daily lifestyle. What has improved since the last inspection? What they could do better: The homeowner, manager and staff at Brooklands House try hard to make sure that the needs of residents living at the home are met and that residents feel comfortable living at the home. However there are a number of things identified at this inspection that could be improved. The most serious concern from this inspection was that a member of staff had been employed without all the necessary employment checks to ensure they were suitable to work with residents. An official letter was left to inform the owner that this must be put right immediately. The Commission For Social Care Inspection will look at the homeowner’s response to this situation again before the next inspection. To ensure that service users are well protected and kept safe, staff who have not done so, should attend a number of specific training courses that includes adult abuse training and some health and safety training. In addition, the induction-training programme that is provided to newly appointed care staff should be audited against the nationally recognised induction training standards to ensure compliance. Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 7 ‘In-house’ and local community activities could be further developed to provide a structured social programme for residents to enjoy to supplement the occasional activities already arranged. Recording of the administration of medication should be improved to make sure that all recordings are accurate and fulfil recognised requirements at all times. 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 House DS0000009800.V256980.R01.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 Brooklands House DS0000009800.V256980.R01.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,in part The pre admission document is now more comprehensive in content to ensure sufficient detail is obtained to make an informed decision. EVIDENCE: Since the last inspection, the pre admission assessment document has been reviewed and revised to good effect. As observed, the content of the document now contains information in sufficient detail for the homeowner/manager to make an informed decision as whether the current strengths and needs of the prospective service user could be met at the home. In addition, there was evidence of other professional assessment information having being obtained along with relevant risk assessments. This collective information is then collated to form the basis of an initial care plan. Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&9 There is a more consistent care planning process in operation in respect of some care plans however this task has yet to be completed to ensure all care plans are holistic in content and accurately reflect the needs and requirements of each service user. The systems for the administration of medication are in the main adequate, however improvements to the recording of medication administered should be made in order to protect service users. EVIDENCE: Since the last inspection there has been a significant improvement to the care planning process. A number of recently developed care plans were evidenced that clearly identified current individual strengths and needs to provide staff with sufficient detail to ensure care practices are consistently followed. However, this process has yet to be completed in respect of all care plans and must be addressed as soon as possible. In order to ensure that the care plan is holistic in content, it is strongly recommended that all aspects of social care needs and religious requirements are incorporated in the document along with any other requirements that are specific to the individual. Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 11 In addition, it is important that the outcome of any risk assessments be incorporated in the individual care plan to ensure safely and to inform staff. At present, care plans are not routinely formally reviewed on a monthly basis and outcomes recorded. In accordance with Standard 7.4, the individual care plan should be reviewed by care staff at least once a month, updated to reflect changing needs and current objectives, and actioned. All care plans should be drawn up, wherever possible, with the service user, recorded in a style accessible to the service user and agreed and signed by the service user. In instances when a service users does not have the mental capacity to fully understand or sign their care plan, with the service user’s permission, a relative/representative could be approached to discuss the content of the care plan and sign the document on behalf of the resident. Where a service user does have capacity but does not wish to become involved in the care planning process or sign their care plan, this should also be recorded on the care plan. Service users spoken with were in the main, not really aware of their individual care plan but confirmed that their personal and health care needs were being met to their satisfaction. The home’s medication policy and procedures were not available for inspection during the course of this visit as they are currently under review and amendment. In line with the existing document, all service users who have capacity and wish to do so are enabled to self-administer their own prescribed medication. Lockable boxes, that are to be attached to the individual bedroom wall have now been purchased for the safe storage of medication or other items of a personal nature and will be fitted in bedroom accommodation in the near future. A monitored dosage system for the administration of medication has been introduced. In the main, drug administration records were accurate although occasional dose omissions without explanation were noted. However the record of controlled drugs administered was less accurate with a controlled drug administered to one service user not countersigned by a second member of staff for several days and on four administrations the controlled drug record for a different controlled drug had not be signed at all even though it was apparent that the controlled drug had been administered. It is essential for the protection of service users, management and staff that there are consistently accurate records maintained for the administration of prescribed drugs. The drug administration record should be signed immediately after the medication has been administered and requirements in respect of the administration and record of controlled drugs must be fulfilled at all times. Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 12 It was pleasing to note that as recommended in the last inspection report, all care staff have now received certificated medication training provided by the pharmacist who supplies the home with the monitored dosage system medication. In addition, it is understood that that the three members of staff with designated responsibility for the administration of medication are waiting for a commencement date to undertake a more advanced medication course of study. Brooklands House DS0000009800.V256980.R01.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 formal social activities are arranged on a limited basis throughout the year, activities provided ‘in house’ or in the local community could be extended to enrich service users social opportunities. Service users are encouraged to keep in regular contact with family and friends in order to maintain family and friendship links. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choice. EVIDENCE: During the course of the inspection it was observed that the routines of daily living and activities remain flexible and varied to meet individually assessed needs. Service users, wherever possible, are enabled to exercise choice in their chosen daily routines that was confirmed through discussion with several service users. Social relationships are encouraged either through family/friends visiting at a time of the service users choice or social stimulation in the wider community. Through discussion with members of staff, a resident and a relative who was visiting at the time of inspection, it was confirmed that generally activities are arranged in response to the requirements of specific a resident such as knitting and jigsaws rather than a planned broad programme of weekly activities that Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 14 could be enjoyed communally by the majority of residents accommodated. Whilst it is acknowledged that the majority of current residents are not interested in board games or bingo, residents could be asked what sort of activity they use to enjoy and activities arranged that are staff led to encourage and enable residents to participate. This is of particular importance in respect of service users experiencing a degree of dementia that may not have the mental ability to express themselves very well. Family and friends could be asked what the service user enjoyed or still enjoys and this information should be then incorporated in the care plan. Alternatively, the staff group could collectively arrange a variety of ‘in-house’ social activities such as singing/music/tea dances etc to help establish the activities residents responded well to and arrange an activities programme around this. Staff spoken with and the relative spoken with did confirm that occasional activities do take place such as coffee mornings, clothes parties and it is understood that a concert is to be arranged in the near future that is hoped will become a regular event. It is also understood that the management team are currently trying to arrange a trip around the illuminations and also Christmas activities in the local community for residents to enjoy. Brooklands House has a policy regarding the six principles of care evidenced at inspection that includes the values of autonomy and choice. This document outlines the home’s philosophy in enabling residents to exercise choice and control over their lives. All service users are encouraged to maintain control of their own financial affairs for as long as they wish to and have capacity to do so. Leaflets in respect of local advocacy services are made available to residents and relatives in entrance hall of the home and also referred to in the Service User Guide. It was clearly evident that residents are able to bring personal possessions with them into the home to make their private accommodation more homely and personalised and also to ease the transition into residential care. It is understood that residents are made aware that they can have access to their personal records and that confidential information in respect of themselves is maintained at the home. Service users at Brooklands House are offered a varied, wholesome and nutritious diet with menus designed to incorporate the known likes and dislikes of service users accommodated. Specialist diets in respect of religious, cultural or medical need can be accommodated and as observed, hot and cold drinks and snacks are made available throughout the day. The majority of service users spoken with were positive in their comments regarding the quality and variety of the meals served. One resident described the meals as ‘very good’ and confirmed a choice is made available and another resident also said that the meals were ‘good’ and that she always enjoyed the food served. Although Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 15 there is a rotating menu available, main meals are generally determined by what is in season and if there were anything that residents would particularly like to eat on a specific day. The inspector observed the lunchtime meal being served that was attractively presented and residents spoken with stated they had enjoyed the meal. It was noted that staff discreetly and sensitively offered assistance as required to ensure the dignity of the resident in both when assisting the resident to eat and in not drawing attention to the resident. Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 16 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 in part The home has developed a satisfactory complaints system and adult abuse policy and procedures for the protection of service users. However as recommended in the last inspection report, staff have yet to receive formal training in the area of abuse and protection. By undertaking specific training in respect of these issues, staff would be provided with increased knowledge and understanding that would further protect service users. EVIDENCE: Since the last inspection, the Commission For Social Care Inspection received one anonymous complaint in respect of Brooklands House. This was investigated by two inspectors from the Commission For Social Care Inspection and found to be unsubstantiated. As identified at the last inspection, there is a satisfactory complaints procedure that is displayed in the entrance hall and also incorporated in the Statement of Purpose and Service Users Guide to inform service users and their relatives of how to make a complaint. However as recently recommended, consideration should be given to devising a structured complaint record form to record the nature of the complaint, detail of the investigation, the outcome of the investigation, any action taken as a result of the investigation and the date the complainant was informed of the findings of their complaint. Although a number of policies and procedures were evidenced for the protection of service users that now include physical restraint, physical intervention by staff and aggression towards staff, as well as a robust adult Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 17 protection policy and staff whistle blowing policy, a policy and procedure in respect of service users monies and valuables could not be evidenced during the course of the last two inspections. However through discussion with the manager, it is understood that a policy and procedure is available in respect of this issue. The manager was asked to provide the Commission For Social Care Inspection with copies of these documents with the Action Plan. It was also observed that the policy in respect of aggression towards staff states that ‘staff should be trained to recognise early warning signs of potential aggression’. It is understood that to date, staff have yet to receive this training. As previously recommended, staff have still not attended formal abuse and protection training that would strengthen their knowledge and understanding of the topic despite this being made a requirement in several previous reports. At the last inspection it was stated that adult abuse training had been arranged to take place in September 2005 however this training did not take place. It is essential that all staff have a thorough understanding of adult abuse issues to protect both service users and themselves and this training should be rearranged as a matter of urgency. Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 18 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): 19 & 26 in part. The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: Service users at Brooklands House live in well-maintained accommodation that is domestic in character and has been designed to meet the individual and collective needs of service users accommodated. All staff has responsibility for reporting any major or minor repairs that require attention. Records are maintained in respect of all on-going maintenance requirements and each item is ‘ticked off’ once the task has been completed. The home is situated in close proximity to Lowther Gardens and the Promenade and within easy reach of local community facilities and resources. The home is well maintained and offers two alternative lounges, one of which includes the main dining area. There is a passenger lift for ease of access throughout the building. As identified in the last inspection report, policies and procedures have been developed for the control of infection and a number of staff have now Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 19 undertaken infection control training. As recommended, consideration should be given for all remaining staff to attend this training to ensure the staff group have sufficient understanding of the topic and a consistent approach is taken in respect of the control of infection. Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 20 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): 29 & 30 in part. Recruitment processes based on the amended Care Standards Act Regulations had not been followed resulting in service users receiving care from a recently appointed member of staff who had not been properly vetted. This potentially leaves people who use the service at risk. EVIDENCE: It was identified at the last inspection that a number of staff had recently taken up employment at the home however a Criminal Record Bureau clearance and POVA first clearance that is required by regulation had not be submitted as part of the recruitment process. These clearances should have been obtained and deemed to be satisfactory prior to the applicants taking up post. At this inspection it was evidenced that the outstanding clearances had now been obtained and were considered to be satisfactory. However, another member of staff who previously worked at the home but then took up employment elsewhere for a period of time has now recommenced employment at Brooklands House. In this instance there was little evidence of any formal recruitment process having taken place. Only one ‘open’ reference was available that was not dated or addressed to a member of the management team. Although the manager stated that she had verbally contacted the referee to confirm the information provided, in every instance all referees should be written to, to request a formal up to date reference that is signed and dated. A second reference was not available at the time of inspection. In addition, the POVA First clearance had not been received until Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 21 several days after the applicant had taken up employment at the home. It is also understood that the person in question already had some qualifications in care from previous employment however there was no evidence that the applicant had been required to evidence the certificates at interview and none were available on her staff file at the time of inspection. An immediate requirement notice was issued for the proprietor to ensure that this situation does not occur and that all appropriate clearances are taken up prior to any further new members of staff starting work at the home. It is imperative that all the requirements of Regulation 19, The Care Homes Regulations 2001 be fulfilled in respect of staff recruitment in order to protect service users and minimise risk. As discussed, consideration should be given to reviewing the application form to make it clear that all POVA First/CRB clearances in respect of care staff will be enhanced disclosures and the information that will be provided by the Criminal Records Bureau as part of the disclosure process. At the last inspection it was clearly evident that induction training is made available to newly appointed staff, however there was no indication that the current induction-training programme had been evidenced against the ‘Skills For Care’ specifications to ensure compliance. This task has yet to be undertaken. As previously recommended, induction training to ‘Skills For Care’ specification should be provided to all newly appointed care staff within the first six weeks of employment. Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 22 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 & 38. Standards 33 & 36 were assessed in part. The homeowner/manager is qualified, experienced and supported by the senior staff in providing leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The homeowner/manager at Brooklands House is competent and experienced, and has achieved a NEBBS management qualification, NVQ Levels 3 & 4 in care and also an NVQ assessor’s award. There are clear lines of accountability within the home with a management structure in place. A manager has recently been appointed and it is understood that eventually this person is to apply for registration with the Commission For Social Care Inspection. Systems are in place to ensure as far as possible the health and safety of service users, staff and visitors. Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 23 Brooklands House has a number of policies and procedures in place to ensure the health, welfare and safety of service users, relatives and staff. These include policies in respect of COSHH requirements, accidents, fire safety, first aid and a health and safety policy. However this last document is now out of date and it is understood that it is to be reviewed and updated to reflect current best practice in regard to health and safety issues. Through discussion with the manager and evidenced through a number of training certificates, it is evident that the majority of staff have undertaken moving and handling and first aid training. The inspector was informed that further training in respect of these issues is to be arranged in the near future for staff who have not attended this training. The manager was asked to advise The Commission For Social Care Inspection in the Action Plan of the date this training has been arranged. It is also recommended that arrangements are made for members of staff that have not undertaken fire safety training, health and safety training, and infection control training to do so and also food hygiene training for all staff that are involved with food preparation, cooking, serving and handling food. As previously stated in this report, the existing induction-training programme should be evidenced against the requirements of the ‘Skills For Care’ induction standards in respect of health and safety training and provided to all newly appointed care staff. It was pleasing to note that risk assessments are in place in relation to the home’s fire procedures and other environment issues and that all equipment is regularly serviced with appropriate certificates available for inspection. It was also noted following discussion a member of the domestic staff team, that NVQ training in domestic tasks that included health and safety safe working practices had been made available. In order to accurately record the training undertaken by the staff team, the inspector advised the implementation of a training matrix, which would show what training had been provided to each individual member of staff and the dates when training that has been undertaken, should be renewed and updated. Since the last inspection, a number of policies and procedures have been reviewed or are in the process of review, however this task has yet to be completed. As identified in the last inspection report, formal staff supervision had been allowed to lapse. At the last inspection, the inspector was informed that the management team anticipated that formal one to one supervision would be reintroduced on at least a monthly basis for all staff covering at minimum all aspects of practice, philosophy of care in the home, career development needs Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 24 and that bi annual appraisals would be introduced. As yet this has not been implemented. Whilst it is acknowledged that staff are informally supervised as part of the normal management process, in accordance with Standard 36.2, all staff should receive formal supervision at least six times a year and formal documented supervision should be introduced as soon as possible in respect of all care staff. Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 25 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 2 8 X 9 2 10 X 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 2 Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 26 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 OP7 Regulation 15 Requirement Timescale for action 31/12/05 2. OP9 13 & Schedule 3 3. 4. OP18 OP29 13 19 All care plans that have not been updated to provide a holistic account of current strengths and needs must be reviewed and updated and the outcomes relevant risk assessments must be incorporated in the care plan. (Timescale of 31/08/05 not met) The homeowner/manager must 31/10/05 ensure that all medication administration records are accurate and up to date. Requirements in the recording of controlled drugs must be maintained at all times. All staff must receive appropriate 31/12/05 Adult Abuse Training (Timescale of 16/09/05 not met) Newly appointed staff must only 10/10/05 take up employment at the home when all the required references and clearances have been received and deemed to be satisfactory. (Timescale of immediate not met) Brooklands House DS0000009800.V256980.R01.S.doc Version 5.0 Page 27 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 OP7 Good Practice Recommendations All care plans should be holistic in content and incorporate detail of individual social and religious care needs or any other specific need or requirement identified. Care plans should be signed by the service user and formally reviewed on at least a monthly basis. All bedroom accommodation should be provided with a lockable storage facility for the safe storage of medication in respect of service users who self medicate. It is recommended that a staff led weekly activity programme be devised in conjunction with service users to provide regular ‘in-house’ or local community activities that service users can enjoy. A complaint record form should be developed to formally record information in respect of the complaint. Please provide the Commission with a copy of the policy and procedures in respect of service users monies and valuables. In line with the home’s policy in respect of ‘aggression’ toward staff, the staff group should undertake training in this subject. Formal training in infection control should be provided to the remaining staff that have not undertaken this training. Copies of the General Social Care Council Code of Conduct should be obtained and made available to all staff. It is recommended that the staff application form be reviewed and updated to inform the applicant of CRB enhanced disclosure requirements. Current induction training should be evidenced against the ‘Skills For Care’ induction-training specifications to ensure compliance. Formal documented one to one staff supervision should be reintroduced. The health and safety policy should be reviewed and updated to reflect current best practice. All staff that has not done so should undertake relevant health and safety training as identified in Standard 38 and a staff-training matrix should be introduced. Please advise in the Action Plan the date further moving and handling and first aid training has been arranged. DS0000009800.V256980.R01.S.doc Version 5.0 Page 28 2 3. OP9 OP12 4. 5 OP16 OP18 6. 7. OP26 OP29 8. 9. 10 OP30 OP36 OP38 Brooklands House Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1 Tustin Court Port Way Preston PR2 2YQ 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 House DS0000009800.V256980.R01.S.doc Version 5.0 Page 29 - 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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