CARE HOMES FOR OLDER PEOPLE
Brooklands Residential Home 16 Harper Lane Yeadon Leeds West Yorkshire LS19 7RR Lead Inspector
Nadia Jejna Unannounced Inspection 2 February 2006 10:15 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 Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 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 Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Brooklands Residential Home Address 16 Harper Lane Yeadon Leeds West Yorkshire LS19 7RR 0113 250 8677 0113 2508677 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) Mr Paul C Jowett Mrs Amanda Jowett Mrs Amanda Jowett Care Home 27 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (27) of places Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The place for DE is specifically for the service user named in the variation application dated 20 September 2004 18th October 2005 Date of last inspection Brief Description of the Service: Brooklands Residential Home is situated near Yeadon town centre, which is a suburb of Leeds. The home is situated within easy reach of local amenities, including the local supermarket, and is on a bus route. The building is an extended and converted detached property. There is a pleasant conservatory on the side of the building, which opens out into a secure and pleasant garden area. Accommodation for service users is provided in nineteen single rooms and four shared rooms. The ground floor has two lounge areas and a dining room in addition to the conservatory. The home provides residential care for up to twenty-seven older people of both sexes. Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 18th October 2005. This inspection was unannounced; it started at 10:15am and ended at 3:00pm. The people who live in the home prefer the term residents, and this is the term that will be used throughout this report. The purpose of this inspection was to monitor the home’s progress and to assess whether the care given to residents meets minimum standards. The manager had completed a pre inspection questionnaire (PIQ), which provided information about the home including maintenance schedules, staff details, training given and policies and procedures. During the inspection records were examined and care staff were seen carrying out their work. Discussions were held with members of staff, the manager, residents and visitors. Comment cards/questionnaires were left for residents and visitors so that they can share their views of the home with the CSCI. None had been returned when this report was written. What the service does well:
Care is provided to residents in a clean, tidy and well maintained home. It is decorated and furnished in a homely manner. Residents said that they felt comfortable, safe, well looked after, their needs were met, that they could not ask for more and were happy with the home. One said that ‘if I didn’t like it I wouldn’t have stayed for twelve years.’ They said that the staff were kind, caring, attentive and that their privacy was respected. They said they could choose when to get up, go to bed and how to spend their time. There are regular organised activities in the home and they can choose if they want to join in with them. Staff in the home have good awareness of each individual residents needs and preferences. It was clear that there were good relationships between the residents and staff. Staff said that training is provided and that they find it useful. Visitors said that they could visit the home at any time and that they were made to feel welcome. Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 6 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 Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 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 Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Current and potential residents will be given information about the home, which will help them to decide if the home can meet their needs. EVIDENCE: The manager and the matron have revised the Statement of Purpose and Service User Guide. The new document was very informative and most of the required information had been included. Advice was given about additional information needed. The manager said that when the alterations had been made it would be made available to current and potential residents. The document also included revised terms and conditions of residence, which will be issued to all residents. Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Residents care needs are met but this is not fully evidenced in the care plans. EVIDENCE: Two care plans were looked at. The formats have been changed and it was clear that staff have worked hard to provide more detailed, person centred information about how to meet resident’s needs. This is good practice and must be continued. Those seen showed that most identified needs had plans in place. During feedback the manager was given examples where plans would benefit from more information. These included where a resident took medication to help them sleep and preferred to sleep with the light on, and making sure that nutritional care plans clearly showed how dietary intake would be monitored and how often weight would be checked. The medicines trolley was secured to the dining room wall. A random selection of medication administration records were looked at, they had been fully completed. A senior carer said that they were enrolling on a certificated medication training course. They had received training in house and given medicines under supervision before being assessed and deemed competent to do this alone.
Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 10 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 and 15 Residents are offered choices in all aspects of daily living, and their visitors are made to feel welcome. Residents receive nutritious, satisfying meals. EVIDENCE: Two weeks menu plans were sent with the pre-inspection questionnaire (PIQ). These showed that varied and nutritious meals were provided. Staff said that one meal was made at lunchtime but that suitable alternatives were offered if residents did not want or like the meal offered. At tea time the menu shows one option but staff said that they ask the residents what they would like or what alternative they would like. Residents said that they were happy with the food choices offered and that the food was good. The kitchen had been fully refurbished last year. It was clean, tidy and well organised. Visitors said that they were welcomed and could visit at any time. They said they were satisfied with the services provided to their relatives/friends and that the staff were kind, caring and approachable. Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 11 Residents said that they were happy with the home. One said that ‘if I didn’t like it I wouldn’t have stayed for twelve years.’ They also said that the staff were cheerful, kind, thoughtful, friendly and caring. Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 12 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 Residents are protected and are able to complain. EVIDENCE: A complaints procedure is in place, which is clear and easy to follow. Residents and visitors said that they knew what to do if they had any concerns and were confident that if any were made they would be dealt with appropriately. The manager said that no complaints had been made since the last inspection. Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 13 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 Care is provided in a well maintained, safe home. EVIDENCE: The home is well maintained. Records are kept which show that appropriate safety and maintenance checks are carried out. Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 14 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): 27, 28 , 29 and 30 Staffing levels are appropriate for the needs and numbers of residents. EVIDENCE: Copies of the duty rota’s had been forwarded with the PIQ. These showed that the home worked to staffing levels that had been agreed before 1st April 2002. Staff said that these were adequate and that they were able to meet the needs of residents. The most recently employed care worker had started two weeks before the inspection. Their file showed that all required pre employment checks had been carried out. They said that they were being well supported by the manager and other staff. They had started the induction training programme, done health and safety training and were to attend moving and handling and infection control training over the next few weeks. Training about dementia was also being held in March 2006. It was clear from discussions with staff and from notices seen about planned training events that steps were in place to make sure that training in health and safety related topics was being kept up to date. The manager said that six staff have qualifications equivalent to NVQ 2 and that three are doing it. It is anticipated that 50 of staff will have this qualification by December 2006. Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 15 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, 35 and 38. The home is well managed and residents benefit from the ethos and leadership of the home. EVIDENCE: The manager has successfully completed the registered managers award and is waiting for this to be confirmed. The manager said that both residents and staff had taken part in quality assurance surveys. The results had been collated and were available to interested parties. The manager said that all maintenance and safety checks for equipment, gas central heating and electrical appliances had been updated by qualified and competent personnel. Copies of certificates confirming this have sent to the CSCI.
Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 16 The accident report forms being used have been purchased from a specialist supplier but do not lend themselves to provide the information needed. The manager said that when the forms in stock have been used they will produce their own forms which will include all the necessary details. It is the home’s policy that they do not look after resident’s financial affairs. The residents and or their relatives look after them. The manager said that small amounts of money would be held in safekeeping if needed, but they were not doing this for anybody. Appropriate records were available should they be asked to do this. Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 17 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 3 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 18 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. 1. Standard OP7 Regulation 15 Requirement Timescale for action 30/07/06 2 OP8 3 OP28 4. OP30 Work on improving the care plans in order to make sure that they provide staff with detailed information on how to meet individual residents needs must continue. 12, 13, 15 Care plans must clearly show 30/07/06 how the needs of residents at risk of losing weight will be met and how this will be monitored. 18 The registered person should 31/12/06 make sure that 50 of the care staff are qualified to at least NVQ level 2 by 31st December 2006. 18 The registered person must 30/07/06 continue to implement and develop the staff training programme. This must make sure that it is appropriate to the work they are to perform and to the assessed and identified needs of the residents. Records must be kept. Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 3. Refer to Standard OP9 Good Practice Recommendations The homes policies and procedures around the ordering, storing, administration and disposal of medications should be revised in line with the Royal Pharmaceutical Guidelines. The registered person should ensure that accident records contain all the relevant information about the incident, including who last saw the service user prior to the accident and at what time, and details of all actions taken and any follow up information as a result of the accident. The fire safety risk assessment should include information that the fire doors to the kitchen and communal lounge are wedged open at certain times of the day and that they must be closed at night. The fire safety officer should be consulted for advice on safe, suitable alternatives for keeping these doors open at key times during the day. 7. OP38 Brooklands Residential Home DS0000001429.V280707.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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