Inspection on 06/08/08 for Brookside Care Home

This inspection was carried out on 6th August 2008.

CSCI found this care home to be providing an Adequate service.

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

Brookside Care Home 22/06/09

Brookside Care Home 13/11/07

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 09/02/2009.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Brookside Care Home 39-41 Chestnut Grove Borrowash Derby Derbyshire DE72 3JP Lead Inspector Janet Morrow Unannounced Inspection 6th August 2008 09:00 X10029.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 Brookside Care Home DS0000069765.V369882.R02.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 and Care Homes for Adults 18 – 65*. 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. Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookside Care Home Address 39-41 Chestnut Grove Borrowash Derby Derbyshire DE72 3JP 01332 666522 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) j_odimay@hotmail.com Mrs Josephine Olaide Adesanya Olugbolahan Adesanya Mrs Josephine Olaide Adesanya Care Home 11 Category(ies) of Dementia (11), Mental disorder, excluding registration, with number learning disability or dementia (11) of places Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mr and Mrs Adesanya may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories:, Dementia, aged 54 years of age and over - Code DE Mental disorder, excluding Learning Disability or Dementia aged 54 years of age and over - Code MD The maximum number of service users who can be accommodated is: 11 13th November 2007 2. Date of last inspection Brief Description of the Service: Brookside is situated in a quiet cul-de-sac in a residential suburb on the outskirts of Derby, and is a home that is converted from two semi-detached houses. Residents are on two floors, with lounges and dining areas situated on the ground floor along with one of the bedrooms; all other bedrooms are on the first floor and include two shared rooms. Lift access to the first floor is available. The home is registered as a care home for 11 people with Dementia or mental disorder aged over 54 years and not falling within any other category. This was changed when the current providers, who were registered on 26 June 2007, took over the home and decided to target their activities on a younger age group, the previous registration being for people aged over 65 years. Nursing care is not offered at the home. Written information provided by the home in August 2008 stated that fees ranged from £344.64 - £364.32 Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection visit took place over one day for a total of 6.75 hours and concentrated on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The manager/owner, two staff, one relative and five people currently accommodated in the home were also spoken with during the inspection visit. One visiting professional was contacted by telephone after the inspection visit. Care records, a sample of policies and procedures and staff information were examined. A tour of the building took place. One complaint had been made to the office of the Commission for Social Care Inspection since the last inspection visit and this was discussed with the manager during the visit. The Local Authority had also received a complaint that they had investigated independently. Written information in the form of an annual quality assurance assessment was received prior to the visit and informed the inspection process. What the service does well: What has improved since the last inspection? Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 6 A plan of activities had been put into place that ensured some form of stimulation was taking place each day and that people living in the home had a reasonable quality of life. Criminal Record Bureau (CRB) checks were in place for all staff. What they could do better: The home must ensure that they have up to date assessments and care plans for all people living in the home. This was raised as an issue at the previous inspection visit in November 2007 and an immediate requirement notice was issued to ensure these were in place. Evidence is needed to show that staff are competent to administer medication and have received training in this area and the home should obtain the relevant guidelines on administering medication. Two people should sign handwritten medication administration record (MAR) charts to reduce the risk of errors. Although safeguarding adults training had been undertaken, staff were not familiar with their responsibilities regarding reporting suspicions of abuse. This has the potential to put peoples’ safety at risk and the manager must ensure that staff fully understand their safeguarding responsibilities and obtain a copy of the Derby and Derbyshire Local Authority safeguarding adult procedures. Infection control procedures need to be improved and supplies of protective equipment need to be available at all times. Recruitment procedures need further improvement to ensure all the legally required documentation is in place, particularly in relation to obtaining two written references and a full employment history. Failure to do this does not ensure people living in the home are safeguarded. Some difficulties in covering shifts had led to some staff working excessive hours, which had the potential to compromise the care of people living in the home. The staff rota was also unclear about the number of hours the manager was working. The rotas need to be clear about who is on duty so that a clear audit trail of staff availability and hours worked is available. Although some staff supervision took place, not all staff had received this. It needs to be addressed to ensure that staff, especially regular bank staff, receive the support they need to carry out their work effectively. Staff training could be improved to ensure that staff have specialist skills in dealing with people with dementia and mental health needs and know how to deal with challenging behaviour. Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 7 All staff must undertake food hygiene training and infection control training. Some environmental improvements, such as eliminating odour, improving the garden area, providing lockable storage space in each bedroom and repairing identified furniture enhance the comfort and appearance of the home. The views of visiting professionals should be obtained to assist with quality assurance processes. 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. Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 older people (Standard 6 older people is not applicable as the home did not provide intermediate care), 2, adults 18-65 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inconsistency in obtaining assessment information did not ensure that the home was able to meet all peoples’ needs. EVIDENCE: Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 10 Two peoples’ care files were examined and one had an assessment in place that gave sufficient information to establish that needs could be met and there was information available from the assessment and care management process. Risk assessments were in place on one file for nutrition, falls and pressure sores. However, the other file had no information at all, including risk assessments, even though the person concerned had come to live at the home recently. It was therefore not possible to establish that the home was able the meet their needs, although the manager stated that she had visited the person prior to admission and was aware of what help they needed. A visiting professional spoken with stated that they were confident that the home was able to meet the needs of the person they were involved with and a relative said that they were ‘very happy’ with the service provided. Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 (older people) 6, 9, 16, 18 and 20 (adults 18-65) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inconsistency in developing care plans had the potential to compromise the quality of peoples’ care. EVIDENCE: Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 12 Two peoples’ care records were examined on this visit. One had a care plan in place that gave sufficient detail for care to be provided and was being reviewed on a monthly basis. The person concerned had signed it, showing agreement to the care. There were risk assessments in place for nutrition and pressure sores and these were being re-assessed on a monthly basis, as required by the indicated score. However, the other file did not have a care plan and there were no details to indicate what assistance was required or any instruction to staff on how to carry out the care for the person concerned. The manager showed in discussion that she had obtained an assessment for use for people with dementia, but this had yet to be utilised. There was also little information on the care plan seen on how to deal with mental health needs. Information relating to visits from health care professionals such as General Practitioner (G.P.), dentists, chiropodists and opticians were recorded. One relative described the care as ‘high quality’ and a person living in the home said the ‘staff deserve a medal’. Four medication administration record (MAR) charts were examined for accuracy of recording. These showed that staff were signing the charts appropriately and using codes to explain when a medicine was not administered. All charts had identity information and allergy information. Two charts were then examined in more detail and were completed accurately, with medicines being administered from the ‘blister pack’ as signed for. However, two people were not signing handwritten charts consistently. Storage of medicines was secure and the medication refrigerator temperatures were being recorded, although there had been no entries for the previous three days. Stocks of medicines showed that medicines were within their expiry dates. The manager stated that there were no controlled drugs on the premises. However, there was no double locking facility for them should they become necessary. The home did not have a copy of the Royal Pharmaceutical Society Guidelines on administration of medicines in care settings. The manager stated that staff had undertaken medication administration training with a pharmaceutical company, and although their information was available, there was no other supporting information, such as a certificate, to show that this training had occurred or any assessment of staff competence. Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 (older people) 12, 13, 15 and 17 (adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Well managed meals and activities enhanced the quality of life for people living in the home. EVIDENCE: Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 14 The home had improved the activities for people since the last inspection in November 2007. The written information provided by the home stated that exercises, reminiscence, bingo, church services and hand massages were some of the options provided. The manager also showed examples of new games that had been provided including memory joggers and a musical quiz. There were notices on display that specified an activity for morning and afternoon each day. During the inspection visit, a ‘sing-along’ took place in the morning, which people said they enjoyed. One person spoken with said they enjoyed the activities at the home and that it ‘wasn’t boring’. Visitors spoken with said they were able visit when they pleased and two people also went out for part of the day during the inspection visit. The manager stated that no one currently had an advocate in the home but she was aware of who to contact if one was required. Feedback from people in the home was positive about the quality of meals at the home and three people spoken with described the food as ‘good’. Standards in the kitchen indicated that purchasing, storage, stock managing and cooking arrangements were satisfactory. A recent inspection from the Local Authority Environmental Health Department had assessed food safety and hygiene as ‘good’. The four-week menu indicated that a choice was available for the lunchtime meal if people did not want the main option, and there was a cooked option on alternate weekends and for the afternoon tea. The menu indicated that people were being provided with a varied and nutritious diet that included some ‘cosmopolitan’ options such as pasta and curry. However, in a written response to a complaint that included food hygiene standards, the home stated that all foods were ‘pre-cooked’ and staff confirmed this on the day of the visit, as the lunch option that day was a ‘ready meal’ from a supermarket and tinned fruit for dessert. There was some fresh fruit and vegetables available in the kitchen but this did not appear to be an integral part of the daily diet. The written information supplied by the home said that the home wanted to improve by encouraging people to eat more fruit and vegetables. Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 (older people), 22 and 23 (Adults 18-65) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Lack of knowledge about safeguarding procedures has the potential to compromise peoples’ safety. EVIDENCE: The home had a clear complaints procedure that was on display in the entrance to the home and people spoken with said they knew who to speak to if they had any concerns. One complaint had been received at the office of the Commission for Social Care Inspection since the last inspection in November 2007 and this had been investigated and a full response received from the owner. The manager stated that their had been no other complaints received at the home. Appropriate procedures were in place to safeguard and protect people from harm and these included ‘whistleblowing’. However, the home did not have a Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 16 copy of the Derby and Derbyshire Local Authority Social Services safeguarding procedures. In discussion, neither member of staff spoken with were aware of their responsibility to report suspicions of abuse, despite training in this having occurred in January, May and July 2008. This meant that people in the home may not be protected from harm. Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 (older people), 24, 26 and 30 (Adults 18-65) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some aspects of the home’s maintenance and infection control procedures were insufficient to ensure that the home was always comfortable and hygienic. EVIDENCE: Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 18 A tour of the building was undertaken and bedrooms were seen that indicated these had been personalised with individual possessions. However, two bedrooms had an odour, two did not have lockable storage space and one had a broken chest of drawers. The remainder of the building was odour free and was clean, tidy and well maintained. There was an outside garden that was available for use, although some improvements were needed to make it more attractive. The written information supplied by the home stated that clearing the garden and employing a gardener was how they intended to improve the environment over the next twelve months. The laundry area was secure and had one washer and one dryer, which were industrial style equipment and suitable for purpose. Peoples’ feedback about the laundry service of the home was positive and all people in the home wore clean and well-presented clothing. Staff were knowledgeable about infection control procedures. However, during the inspection visit, it was identified that the supply of protective aprons had run out. The manager, therefore, made a telephone call during the visit to order more aprons. Neither member of staff was seen using either gloves or aprons during the visit, even though they moved from cleaning to care duties during the course of their shift. This practice does not ensure that potential infections are controlled. Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 (older people), 32, 34 and 35 (Adults 18-65) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Discrepancies on the staff rota, lack of specialist training and shortfalls in recruitment information have the potential to adversely affect the care and safety of people living in the home. EVIDENCE: The staff rota for 21st July 2008 – 17th August 2008 was examined. This showed that there were two care staff on each shift in the day and one at night. The manager said there was also a sleep-in member of staff but they were not designated on the rota. Care staff also completed cleaning, cooking Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 20 and laundry duties. There was a programme that listed when these tasks were to be undertaken. The shift pattern was a thirteen hour shift from 7am – 8pm; whilst staff said they did not mind working these hours, one member of staff on duty was on the rota as having to work twelve consecutive shifts as she had worked her day off to cover for sickness. Part of the complaint raised with the Commission for Social Care Inspection related to long hours and staff being tired and the potential for this was in evidence and consequently had the potential to adversely affect peoples’ care. The hours that the manager worked were also not clear on the rota. It designated her as working an early and late shift and being the waking night staff member as well on Mondays – Thursdays each week. She stated that she did have rest periods on each shift but this was not designated on the rota. Three staff files were examined for recruitment information. These showed that there was some information required by the Care Homes Regulations 2001 missing from staff files; all three had only one written reference, none had a full employment history and the Protection of Vulnerable Adults (POVA) First checks showed that these were received after the person had commenced work at the home. All three had a Criminal Record Bureau (CRB) check in place. Recruitment issues were raised as an issue at the previous inspection in November 2007 and need further improvement to ensure legal requirements are met. The written information supplied by the home stated that three of eight members of staff had a National Vocational Qualification at level 2 and a further two staff were undertaking the training. The home was therefore meeting the target of having 50 of staff having an NVQ2. Mandatory health and safety training had taken place throughout 2008 and there had been dementia awareness training in June 2008. However, there had been no in depth training on dementia or mental health needs although this is the home’s specialist registration. There had been no formal training on dealing with difficult behaviour and one member of staff stated that they found this part of the work the most difficult. The manager stated that informal information giving sessions on tissue viability and on foot care had been given by visiting professionals. Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 22 31, 33, 35 & 38 (older people), 37, 39 & 42 (adults 18 – 65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some aspects of management did not ensure the home was run in the best interests of people living there. EVIDENCE: The manager was registered with the Commission for Social Care Inspection and had a number of relevant qualifications including the Registered Managers (Adults) Award. She had a good range of previous managerial and mental health experience. However, there were issues around recruitment of staff, staff working practice and specialist training as identified earlier in the report that needed further improvement and development. Quality assurance was in the process of being developed. Meetings with people living in the home had been held, the most recent being in July 2008. The records of this meeting were seen and showed what action was to be taken to improve the service. For example, it stated that new dining room furniture was to be provided. Staff meetings also took place, the most recent being recorded as January 2008. A survey for people living in the home had been undertaken but it was not clear what action had been taken to address any of the comments. There had been no surveys or collation of views from visiting professionals. One letter of thanks received in July 2008 from a relative said it was ‘very much appreciated how you all looked after her’. Some staff supervision took place but the written records showed that only two staff had received formal supervision and this had occurred in 2007. The manager stated that she was not acting as appointee for anyone’s finances. Personal allowance transactions were recorded. Two peoples’ financial records were examined and corresponded accurately with the cash held. The cash was stored securely. The written information supplied by the home stated that maintenance checks were up to date. This was verified on the visit when certificates were seen showing gas safety was checked in June 2008 and portable electrical appliances in December 2007. There was safety information on products relating to the Control of Substances Hazardous to Health (COSHH). Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 23 The written information also stated that policies and procedures had been reviewed in 2008. Staff training in mandatory health and safety areas had taken place during 2008. Training certificates confirmed that courses had been undertaken in first aid, food hygiene, moving and handling, fire safety and infection control. However, there were still some shortfalls; the written information stated that only four of the eight care staff had undertaken infection control training and the complaint raised with the Commission for Social Care Inspection stated that not all staff working in the kitchen had done food hygiene training, which was confirmed during the visit from staff records. Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 24 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 X 2 X 3 2 4 3 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 2 25 X 26 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 2 37 X 38 2 Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 25 YES 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 OP3 Regulation 14(1-2) Requirement All people living at the home must have their needs for care and support fully and comprehensively assessed and this must be kept up-to-date so that staff can work consistently and safely and provide the proper support at all times. This must include any areas of their lives that present risk to safety and wellbeing. This requirement had a timescale of 31/03/08, which has not been met. Immediate requirement notice issued. There must be a detailed care plan in place for all people living in the home to ensure that staff know how to meet their needs. Immediate requirement notice issued. There must be evidence available that staff have received training in administering medication and that their competence to do so has been assessed. This is to ensure that medication is handled safely and administered correctly. DS0000069765.V369882.R02.S.doc Timescale for action 08/08/08 2. OP7 15(1-2) 08/08/08 3. OP9 13 (2) 31/10/08 Brookside Care Home Version 5.2 Page 26 4. OP18 13 (6) The manager must ensure that all staff know and understand the correct procedure if they suspect abuse may have occurred. This is to ensure that people living in the home are safeguarded. The manager must ensure that all staff implement proper infection control procedures and that there are always adequate stocks of protective equipment to ensure the safety of both staff and people living in the home and to control the spread of infection. The staff rota must be accurate and clearly detail who is working and for what hours, including the manager. Recruitment information as detailed in Schedule 2 of the Care Homes Regulations 2001must be obtained for all staff prior to them commencing working at the home to ensure the safety of people living there. All staff must receive specialist training in dementia, dealing with challenging behaviour and mental health needs to ensure they are competent caring for people living in the home. The system of formal pre planned 1-to-1 meetings of the home’s management with staff must be reinstated and should occur 6 times per year so that staff are given opportunities to be consulted in confidence and their work can be properly monitored. DS0000069765.V369882.R02.S.doc 30/09/08 5. OP26 16 (2) (j) & (k) 31/10/08 6. OP27 18 (1) (a) & Schedule 4 (7) 19(1)(b) and Schedule 2 31/08/08 7. OP29 31/08/08 8. OP30 18 (1) (c) (i) 31/10/08 9. OP36 18(2) 06/09/08 Brookside Care Home Version 5.2 Page 27 This requirement had a timescale of 31/12/07, which has not been met. Timescale extended by one month from inspection. 10. OP38 18 (1) (c) (i) All staff working in the kitchen must receive food hygiene training and all staff must complete infection control training. This is to ensure the safety of people in the home. 31/10/08 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 Two people should sign and date handwritten medication administration record (MAR) charts to ensure they are accurate and minimise errors. The home should obtain an up to date copy of the Royal Pharmaceutical Society Guidelines on administering medication in care settings to ensure they have relevant guidance. The home should consider using more fresh ingredients for meals to ensure a more balanced and nutritious diet. The home should obtain a copy of the Derby and Derbyshire Local Authority safeguarding adults procedures. The odour in the identified bedrooms should be eliminated to ensure the home is comfortable and hygienic. The identified chest of drawers should be repaired promptly. All bedrooms should have lockable storage space. Consideration should be given to reviewing the hours and DS0000069765.V369882.R02.S.doc Version 5.2 Page 28 2. OP9 3. 4. 5. 6. 7. 8. OP15 OP18 OP19 OP19 OP24 OP27 Brookside Care Home designated tasks worked by staff rota. 9. OP33 The views of visiting professionals should be obtained to assist with quality assurance processes. Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Brookside Care Home DS0000069765.V369882.R02.S.doc Version 5.2 Page 30 - 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. 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