Inspection on 08/11/05 for Brookside Residential Care Home

This inspection was carried out on 8th November 2005.

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

The inspector 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 Residential Care Home 15/08/06

Brookside Residential Care Home 09/06/05

Brookside Residential Care Home 20/12/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Brookside Residential Care Home 159 Eccleshall Road Stafford ST16 1PD Lead Inspector Mrs Joanna Wooller Unannounced Inspection 8th November 2005 10.00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brookside Residential Care Home DS0000061715.V264674.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. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brookside Residential Care Home Address 159 Eccleshall Road Stafford ST16 1PD 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) 01785 240738 Mrs Margaret Ann Rowlands Robert James Rowlands Mrs Margaret Ann Rowlands Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 MD Minimum age 50 years on admission Date of last inspection 9th June 2005 Brief Description of the Service: Brookside Care Home is a family run care home. The providers Mr and Mrs Rowlands have owned the home since August 2004.The home consists of 17 single bedrooms and four double bedrooms, most with en-suite wc facilities. The spacious sitting room and the refurbished conservatory allow a choice for the service users and complement the homely environment. There are cosy rooms set aside for quiet times. A passenger lift is provided in the home to allow ease of movement between floors for service users and staff. The dining rooms and refurbished kitchen reflect the care that has gone in to providing the highest standard of food preparation. The chef post is presently vacant, however the catering staff continue to produce imaginative menus, ensures the meals are presented to reflect the quality of produce purchased, and the individual dietary needs of the clients are addressed. Outings and planned entertainment provide social stimulation for the service users. Relatives are encouraged to participate when possible. Both single persons and married couples are welcomed in to the home. To the rear of the home there are stunning views of the garden and local marshes. The homes decoration and furnishings were seen to be good quality and the atmosphere at the home was warm and relaxed. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced visit was made on the 8th November 2005 at 10.00hrs. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including pre and fieldwork, amounted to 6.5hrs. The Providers Mr and Mrs Rowland’s were not present at the home. The home was in the charge of Mary Jones the senior carer and four care assistants. The ancillary staff on duty included a cook and a domestic. The staffing levels were evidenced as being adequate to meet the needs of current 25 residents in the home. The inspection included the following elements; A tour of the building, observation and inspection of records relating to provision of care, discussions with several residents, discussions with staff members on duty, observation of services within the home such as catering and laundry, and an inspection of the managerial aspects such as staffing issues and health & safety. Since the last inspection no complaints had been received and no additional visits had been necessitated. It was evident that all aspects of care had again been well addressed, with residents able to choose to live at the home following an assessment and a visit to the home. Service user plans had been well written, based on the community care plans completed by social workers. There was evidence that health, personal and social care needs had been met and were generally well documented in individual files. Privacy, dignity and choice aspects for residents were being upheld and observed to be offered by the staff. No residents had attended an A&E department, and no resident had a pressure area. The home was fit for purpose and provided a safe environment for the residents and staff. The home was again noted to be exceptionally clean and tidy. Health and safety aspects had been given a high priority and it was noted that the outside risk assessments were still to be completed. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 6 Recruitment and retention of staff aspects were good with little staff turnover. Staff training had been given a priority, with induction training being followed by NVQ training, and staff had received some supervision. Records had been correctly filed and stored. What the service does well: What has improved since the last inspection? What they could do better: • • The risk assessments identified at the last inspection were still to be completed. This must include outdoor equipment, steps and other hazards. Care records were still found to be either not signed or dated in several place in the care records inspected on the day. One resident had no care plans at all and relatives or the resident did not sign other care plans which were identified. Care records were not updated monthly along with some risk assessments as discussed. The Care Managers duties were not identified on the staff rota and this should be rectified immediately. • • Please contact the provider for advice of actions taken in response to this Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brookside Residential Care Home DS0000061715.V264674.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 Brookside Residential Care Home DS0000061715.V264674.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 Prospective service users have the opportunity to exercise individual choice about where to live, supported by the information available at the home and the robust pre admission assessment and procedures. EVIDENCE: The documentation seen, and following a discussion with residents, evidenced that residents had been assessed prior to admission and they had been enabled to make a choice about the home. Those involved had the opportunity to visit the home prior to choosing to stay. A couple of ladies spoken to had visited the home, and spent the day there and had a meal prior to deciding to stay. The community care plans provided by the social worker, as part of the individual needs assessment process, were used to support the initial service user plans. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 10 Residents that were spoken to were asked and confirmed that they had been fully involved and were in agreement with the assessments. The records seen and a discussion with the staff evidenced that care staff, individually and collectively; continue to have the necessary experience and skills to meet the assessed needs of the current service users. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 11 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): 7,8,9 and 10 Care records were generally well recorded and initial assessments were reviewed and some were updated but not all. One resident had no care plan. Medication policies and procedures were followed. There was evidence that residents were treated with respect, privacy and dignity, during the caring process. EVIDENCE: Several service users previously spoken to all commented positively about the care being provided. They felt that the staff were exceptionally kind and caring and again spoke very highly of them. The service user plans and associated documentation was generally well written and reflected the current condition of most residents. It was noted that the documentation seen did have omissions such as not being updated monthly, not signed, dated or reviewed. Personal care needs were being met, however some individual risk assessments and social care plans were not updated. One resident had no care plans, no likes and dislikes identified and no Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 12 social interests documented. This should be compiled as a matter of urgency. Some care plan reviews were not evident between June and October and initial risk assessments were not dated. Care records had space allocated for resident photographs but were not in place. NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. A local GP practice services the home, and there is a good working relationship with them. Boots pharmacy supply, monitor and audit the medication systems, records of their visits and outcomes were seen documented. During the inspection it was again observed that privacy and dignity were being offered to residents, and there was very good interaction with staff. Care staff were seen knocking on doors before entering. A group and individual residents spoken to told the inspector that they were treated with respect, and that the staff were very good. Most residents spoken to said they felt content with their life in the home. Brookside Residential Care Home DS0000061715.V264674.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, 14 and 15 Residents were content with their lifestyle in the home, and they had been able to exercise choice and influence decisions affecting them. Full contact had been maintained with relatives and friends of residents. Many opportunities to access the local community had been made available. Catering services were very good with balanced nutritious meals being served, considering residents’ individual choice. EVIDENCE: Only one resident told the inspector that they had been able to influence some aspects of the running of the home e.g. mealtimes, menus. Contacts had been maintained, where possible, with relatives and friends and this was seen documented. Several visitors attended the home during this inspection and they discussed with the inspector the good links and communication with them. Residents spoke of their visitors and their involvement with the home. Trips out to the community had been limited due to residents’ choice. The staff showed the inspector the activities notice board and photographs, which evidenced the activities both inside and outside the home. Residents spoke of the activities and entertainment within the home. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 14 Residents spoke of their satisfaction with the meals and choices offered. The menus and catering records were examined and evidenced that the dietary requirements of residents were met. The mid day meal seen was well presented and met all nutritional requirements. The cook on duty noted individual preferences. Fresh meat and vegetables were delivered to the home and cakes and pastries were home baked. A vacancy has arisen for a 2nd cook and recruitment is in progress. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 15 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 and 18 Complaints are listened to and resolved as per the complaints policy. The home policies, procedures and staff training, protected residents from aspects of abuse. EVIDENCE: There had been no formal complaints presented at the home and the inspector had not received any either. The inspector observed the complaints policy and procedure documentation, and on discussion with staff and residents, evidenced that complaints would be listened to and dealt with in the correct manner. The inspector saw many ‘thank you’ and complimentary cards from appreciative relatives. No incidents of neglect or abuse had been reported. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. Documentation seen evidenced that the above issues had been discussed at length during staff induction, training and on-going supervision. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 16 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 and 26 The home provides a safe and adequately maintained environment for residents. The home was clean, warm and tidy, and had a very comfortable atmosphere. EVIDENCE: A tour of the building, and a check on the maintenance documentation, verified that the premises were fit for purpose, clean warm and tidy. The duty rosters evidenced that adequate ancillary staff were employed. Staff when asked told the inspector of their knowledge on infection control, and showed him the relevant documentation. Adequate hand washing facilities were available throughout the home. The laundry facilities were seen to be fully compliant. The records evidence that maintenance of the premises was now being given a high priority. On going painting and re-decorating was seen being done. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 17 Hot water temperature checks, and emergency lighting/fire alarm tests were seen up to date and correct. There are no outstanding issues known from the Fire Prevention or Environmental health departments. The toilet areas had required storage and this had been addressed. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 18 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 to 30 The assessed needs of service users had been met by an adequate number of suitably trained staff. Recruitment procedures had been correctly addressed which had contributed to the protection of service users. Staff training had been given a high priority EVIDENCE: The duty rosters seen, and a discussion with the staff, evidenced that adequate numbers of staff had been on duty to meet the needs of the existing service users. Staffing levels were being maintained as at 1st April 2002 and following a discussion with the staff it was agreed that the shift cover was adequate for the existing residents needs. Adequate ancillary staff had been provided each week. Residents when asked stated that staff were available when they wanted them, and that the staff were very efficient and capable. There are 18 care assistants, of which 50 were trained to NVQ level 2 or above. The remaining staff were completing NVQ training or similar. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 19 The homes recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Staff asked stated that they had job descriptions and contracts of employment. Training had been given a high priority and the training records of individuals were seen. The records evidenced that care assistants had benefited from ‘in house’ and external training, which had covered the needs of the registered client group. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 20 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, 35 and 38 The home is evidenced as well managed. Financial aspects were correctly addressed and recorded with safeguards to residents. Health and safety issues had been given a high priority and managed well. EVIDENCE: From observations made, discussion with service users, and discussions with the staff, it was evident that the home was being run in the interests of service users. Quality assurance systems are to commence to assess the services and this will include residents, relatives, visitors and visiting professionals. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 21 A check on the records and a discussion with both residents and representatives evidenced that all service users had the opportunity to handle their own finances and all residents and families had chosen to do so. Any valuables and belongings brought into the home were seen recorded. No health and safety issues were noted during this inspection, including a tour of the home. The documentation seen for checks and examination of plant and equipment was all correct and up to date. The manager and staff spoken to confirmed that health and safety issues are given a high priority. One area to be developed is the risk assessment re ‘Falls’, outdoors and outdoor equipment. Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 23 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. 2. 3. 4. Standard OP33 OP38 OP37 OP8 Regulation 24 13(4) 17 15 (2b/2c) Sch 4 (7) 12 (1a) Requirement Quality assurance systems are to be put in place at the home. Risk assessments are to be developed for falls, outdoor equipment and outdoors. All care records to be dated All residents are to have a care plan and for it to be updated monthly and reviewed with the resident or a representative. The Care Managers hours must be visible on the duty rota each week. All residents are to have individual needs identified and reviewed within the care records. Timescale for action 08/01/06 15/11/05 08/11/05 08/11/05 5. 6. OP27 OP8 08/11/05 08/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Brookside Residential Care Home DS0000061715.V264674.R01.S.doc Version 5.0 Page 25 - 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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