Inspection on 21/04/08 for Brookthorpe Hall Care Centre

This inspection was carried out on 21st April 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

Brookthorpe Hall Care Centre 07/04/09

Brookthorpe Hall Care Centre 14/12/06

Brookthorpe Hall Care Centre 06/03/06

Brookthorpe Hall Care Centre 05/09/05

Brookthorpe Hall Care Centre 13/01/05

Brookthorpe Hall Care Centre 27/05/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

St George`s

5 Seafield Road

Credence House

Poldhu

Queensmount

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Brookthorpe Hall Care Centre Stroud Road Brookthorpe Glos GL4 0UN Lead Inspector Mrs Janice Patrick Unannounced Inspection 21st & 22nd April 2008 6.45 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 Brookthorpe Hall Care Centre DS0000016392.V361387.R01.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. 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. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookthorpe Hall Care Centre Address Stroud Road Brookthorpe Glos GL4 0UN 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) 01452 813240 01452 814394 admin@brookthorpe.org Frampton Residential Homes Limited Mrs Michaela Brisland Care Home 32 Category(ies) of Learning disability (2), Old age, not falling registration, with number within any other category (30) of places Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Two beds can be used for service users under the age of 65 years of age. That service users under 65 years of age must be over 50 years of age. 14th December 2006 Date of last inspection Brief Description of the Service: Brookthorpe Hall is registered to provide personal care for 30 older people, with an additional category for two people with a learning disability. This Care Home therefore does not provide nursing care. The home is very spacious and provides easy access with a staircase and shaft lift accessing all four floors. The home uses contracted caterers offering a good degree of choice of meals for residents. The home has an activities co-ordinator and provides opportunities for social activity and interests. The home is situated off the main road into Stroud from Gloucester. Bus stops are situated within walking distance from the home. There is also a local public house within walking distance. The home makes available copies of the Service User Guide and CSCI inspection reports to prospective residents. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.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. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. Prior to this inspection we, (The Commission for Social Care Inspection, CSCI) sent questionnaires to services users and their representatives asking for their views on the services provided. We also sought the views of the staff employed at the home. The home Inspector carried out this inspection over two days between the hours of 6.45pm and 8.30pm on the first day and 10am and 5pm on the second day. We inspected the care that people were receiving. We inspected the records kept in relation to this and looked at how peoples’ specific health care needs were being met. We explored how peoples’ privacy and dignity is maintained and how they are able to make choices and have a say in what happens to them. We inspected areas that give added quality to someone’s life such as their ability to socialise, opportunities for recreational activities and the choice and standard of food. We looked at how the home protects people from abuse, which included the home’s policy and procedure and additional areas such as staff recruitment and staff training. Arrangements for the general management of the home were inspected and included a look at staff rosters and health and safety records. We inspected how the service seeks the views of interested parties on its performance and how any improvements to the service are planned and carried out. During this inspection we also looked into possible breeches against the Care Home Regulations 2001 with regard to two complaints. One was initially made to the Registered Provider, however the complainant remained dissatisfied in how this had been investigated and the other remained with the Commission to investigate. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The pre admission assessment needs to be more robust and should be carried out each time a person is admitted for respite care so that any changes in their health or personal care needs are adequately identified. Some people may not be getting enough information about the home prior to their admission. This may not be the fault of the home, in the case of an emergency admission, but how information is being made available maybe worth a review. Care planning needs robust auditing and senior staff who are responsible for writing these, require support to make the content more relevant to the person’s needs. All identified needs must be accounted for and appropriate action taken in response. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 7 Systems in the home must be managed so that unnecessary risks to the people in the home are avoided. This would include improving the homes recruitment practices and only employing staff who have been appropriately cleared by the Criminal Bureau Records and against the Protection of Vulnerable Adults (POVA) list. Staff must also have satisfactory and appropriate references. The Registered Manager must be clear about her responsibilities and legal status, even in relation to systems and areas of management that she may not physically be taking a lead on. 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. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 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 Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Information about the home is made available to some people prior to their admission to help them make an informed decision about the home and its services. Others maybe finding themselves in a position where the admission is so quick, that this is not possible. Some people are not benefiting from a robust pre admission assessment. This puts people at risk of their current care needs not being adequately identified. EVIDENCE: Information about the home is available within two documents that are on display in the home’s reception area. These are called the Statement of Purpose and Service User Guide. We were told that each person is given an edited version of these documents on admission; an example of this was seen in someone’s bedroom. The home’s Annual Quality Assurance Assessment (AQQA) tells us that this information is Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 10 also handed out to prospective residents when they initially look around the home. People said, in five out of the seven questionnaires received back by us that they had not received enough information about the home prior to moving in. There may well be reasons outside of the home’s control for this response such as a funding authority organising the placement, an emergency admission or the admission being organised by family/representatives on behalf of the resident, without visiting the home beforehand. We suggest the home explore this to see if anything can be done to improve peoples’ knowledge of the home before they are admitted under such circumstances. We saw two examples of peoples’ care needs being assessed by staff from the home before they moved in. Both people were previously in hospital and the information gathered was brief in content although gave enough information for staff to generally understand the person’s main needs. We identified a shortfall in this process in the case of another person who regularly stayed at the home for periods of respite (short) care. Documents showed that a fresh assessment had not been carried out prior to the most recent admission. Despite some of the person’s current needs and problems being put in writing on the day of the admission by the person’s main carer, as guidance for staff, these were not acknowledged and consequently appropriate care was not planned. This resulted in a shortfall in this person’s care, which led to a complaint being made. Although on most occasions information is being gathered prior to someone’s admission and the home’s Annual Quality Assurance Assessment (AQQA) tells us this process is taking place, the written evidence is generally weak and was totally inadequate in one example. The AQQA does say that the pre admission record form is to change so this may help to make the improvements that are required. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although currently the majority of people are happy with the care they are receiving, there is a danger, through a lack of good assessment and care planning, that one incident of poor care, could be repeated. EVIDENCE: In assessing this outcome the Key Lines of Regulatory Assessment (KLORA) were applied so that a proportionate assessment could be made. We have therefore assessed that the outcome for many people in the home was satisfactory, but the shortfalls in assessment and care planning has compromised the care of one person already and unless improved upon will place others at risk. We inspected the records of one person who had received care at the home and which had resulted in the family and the person’s own carer being unhappy with the standard of care provided. We have explored the care given to this person in retrospect as the person had already completed their period of respite care. There was clear evidence to Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 12 suggest that there had been changes in this person’s health and care needs as these were verbally handed over to the home staff on admission and put in note form for staff reference. Despite this staff failed to acknowledged these and incorporate them into the person’s plan of care. The shortfall continued as care staff began to report observations as they cared for the person, but senior staff failed to act on these. We are aware that staff are dealing with a diverse group of needs and that many people we spoke to or who commented in the questionnaire we sent out prior to this inspection, are very happy with the care they receive. However, we looked at the care documentation for four other people. We saw that some peoples’ care plans fully identified the care need and gave good guidance to staff on how this should be met. But, we also saw evidence of recorded observations/reports from care staff of areas of care that required addressing where there was no evidence to suggest that this had been carried out. The following two examples demonstrate that this could have a significant impact on someone’s health if not competently followed though and managed. One was an entry by a carer describing the deterioration of a person’s skin. They had noted that this looked sore and were reporting what they should be reporting in relation to potential pressure sores. However, there was no further record of this after the initial entry, there was no care plan relating to this and any evidence of a review being done of the skin. The second relates to a person’s weight. The weight recorded on the chart was 32.9kg, a drop of nearly 2kg from the previous months weight. Despite this senior staff had recorded ‘no changes’ on this person’s care plan. Therefore the loss had not been acknowledged. Staff have received training in the use of a nutritional assessment tool, which is devised to be used in such circumstances to help staff monitor this very situation. We therefore observed the support given to people who require help at mealtimes and this was carried out in a very attentive and respectful manner. We spoke to the Registered Provider about these potential serious shortfalls and suggested that close auditing of what is being written in the care plans takes place and that senior staff are supported to understand what their responsibilities are. The Registered Provider confirmed that she was liaising with the Care Home Support Team and the plan was to have some training sessions on care planning and record keeping. We did observe a senior member of staff taking a lot of time to reassure a very distressed person, who had forgotten that her family had recently visited. We were able to evidence people having access to external healthcare professionals. One person was having wounds to her legs monitored and redressed by the Community Nurse. The Speech and Language Therapist had assessed another person. We saw a written care plan giving guidance to staff that was based on this specialist’s instructions. The Continence Advisor had assessed another person and several people had been in contact with the Mental Health Team at some point. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 13 The majority of questionnaires received back from service users or their representatives, agreed that they always received medical attention when it was needed. We inspected the medication system as well as relevant records. These demonstrated that correct records are kept on receipt of medication from the Pharmacist and of medication being returned. Records following administration were generally well kept with no gaps in the records inspected. There was one handwritten direction without a second signature. Medication that is open to misuse, such as Diazepam was checked. This showed that the records of administration were correct in relation to the stock balance. We suggested that these types of medications be added to the monthly audits already being carried out on certain sleeping tablets and antibiotics. The medication cupboard requires rag and raw bolts to replace the normal bolts that are in place. We did not see any situations during this inspection that led us to believe that peoples’ privacy and dignity may be compromised. We read the care plans for one person who had been admitted for respite care, which was being extended. This person had a lot of care needs and was terminally ill. The discharge summary from the hospital was brief and although the home had planned how immediate needs would be met, there was no evidence to demonstrate that there had been any recognition of the condition that this person was eventually going to die from. There was no reference to end of life wishes or preferences that the person may have if they were to deteriorate whilst staying in the home. This may have been because the person was effectively just staying in the home for a short period of time and hoping to return home. But equally so, another resident who is a permanent resident, with very specific problems also had no reference to some of the main issues of care within their care plans. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although it would appear that the provision of activities and entertainment has been limited for several months, plans are in place to improve this and people certainly appear able to carry out their preferences and to make certain independent choices. EVIDENCE: In assessing this outcome the Key Lines of Regulatory Assessment (KLORA) were applied so that a proportionate assessment could be made. We were told that the home has not had a designated activities co-ordinator but that one member of staff has just completed training in this. We spoke to this carer and she told us about she hopes to develop this role. Comments within the questionnaires sent to people living in the home and to relatives highlighted this as an area that needs improvement. The day after this inspection was St Georges Day and her plan was to produce a St Georges flag, with the help of the residents. We observed her colouring this in by herself with five out of eight residents asleep in the lounge at 3pm. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 15 We commented on the lack of resident involvement and were told that no one had been interested and she wanted to complete the flag for the dining room by tomorrow. The Annual Quality Assurance Assessment (AQQA) points out that the home have found it difficult to improve the provision of activities in the home, due to the very strong reluctance of residents to get involved. We were told that there had not been any visiting entertainment since Christmas, although one was due to visit next week. One member of staff commented: ‘it has been quiet on the activities front for 3-4 months now’. One resident told us that he had enjoyed his usual Bingo game, held every Tuesday. On one morning we witnessed residents enjoying a quiz. There did seem however, a shortfall in activities/interaction for those that are less able and maybe this is an area that can be improved upon once the activities carer is established in her role. The Annual Quality Assurance Assessment (AQQA) tells us that there is a focus on peoples’ equality and diversity needs. We spoke to several people about how they spent their days and most said they were content and enjoyed living at the home. We received a complaint from someone who had stayed at the home over the Christmas period. Amongst several points raised, which have also been investigated by the Registered Provider, was the poor provision of activities and entertainment over the Christmas period. This person also considered the food to be of poor quality and questioned the quantity of the food provided. We therefore also looked at the arrangements in place for the provision of food and choice of food. We were able to speak to the Operations Manager of the external catering company that provides this service. She confirmed that she had been asked by the Registered Provider to seek the views of residents on the food provided following this complaint and all were content with the service. Certainly the comments we received back during the site visit and within the questionnaires were positive. There is a daily choice provided at lunchtime, including alternatives to this. People spoken to on leaving the dining room had enjoyed their food. One person said: ‘it’s always been good’. Staff can provide basic sandwiches and drinks outside of the kitchen hours (i.e. past 8pm) There have been some changes in the kitchen staffing recently and on the day of this inspection there was a new chef and assistant. He was planning to review the menus as he felt that the descriptions given on the menus were too confusing, ‘it needs to be names that they recognise’, ‘dishes that they may well have cooked themselves when at home’. The home’s Annual Quality Assurance Assessment (AQQA) tells us that menus are devised with involvement from the residents. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 16 The chef was knowledgeable when it came to the dietary needs of those who were losing weight and who are diabetic. This particular person had had previous experience of working within a care home. The home must ensure that it keeps a record of what sandwiches are prepared each day. We observed visitors arriving at various times of the day, free to come and go as they chose. Advocacy contact points and advice was seen on the notice board along with guidance on the Freedom of Information Act in relation to care records. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for people to make a complaint but how the home responds to these needs improvement to reassure people that their complaint is being taken seriously. Despite staff receiving training in abuse issues and the home having a comprehensive policy on this, all of this good intention is compromised by poor recruitment practice. EVIDENCE: In assessing this outcome the Key Lines of Regulatory Assessment (KLORA) were applied so that a proportionate assessment could be made. Despite two recent complaints being received this is not a service that we would normally receive a high number of complaints or concerns about. We have received two complaints from individuals since the last inspection. As discussed in the outcomes already reported on, one was forwarded to the Registered Provider to investigate. Because the complainant remained unhappy following this and felt that the complaint had not been investigated in a satisfactory manner, some areas were explored during this inspection. The Registered Provider also required prompting to forward their outcome to the Commission. One was the poor quality and quantity of the food provided over the Christmas holiday. We therefore explored the arrangements for food provision and were able to speak to the Operations Manager of the external catering company that Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 18 provides this service. She confirmed that individual residents had been asked about the food as part of their investigation following the complaint. She reported that most had confirmed that they were happy with what was being provided. This would be in line with the comments we received back, both at this inspection and via the questionnaires. Another element to this complaint was a lack of activities and entertainment. This has been reported on in the outcome before this one, ‘ daily life and social activities’. The complainant also said that residents were being asked if they wished to go to bed at 5pm, but being purposely told that it was far later in the evening, if they asked what the time was. We started this inspection at 6.45pm on the first day for this very reason. We wanted to see how many people were in bed by this time and if they were, to find out why and if it were their choice. When we arrived there were six residents in one lounge watching television, four were sitting together in the hall, where there are also comfortable chairs, and another person was on their own in another lounge. We visited every bedroom during the first evening. In one shared bedroom there were two residents asleep. Staff explained that both were very frail and are ready to go to bed after teatime. Another resident was sitting in her room. She said she likes to come up and watch television after tea, but go back down later, which we witnessed. One resident had taken herself to rest on her bed and another had requested to go to bed after tea. Another person goes to bed after tea as she is also particularly frail and is at risk of pressure sores. This person was listening to quiet music, which she likes, and seemed very content. Another resident was in bed and confirmed that this was her choice as she finds it more comfortable than the chair. Another resident was also fast asleep; staff said she always asks to be taken up to her room when she was ready. Another resident was lying on top of her bed and said she likes to do this. Another resident said she likes to be in bed by 7.15pm. In summary, all those in bed on this occasion were either asleep or there was a good health reason why they were there. Several were carrying out their preference to be in their room or resting on their bed. The second complaint, which related to shortfalls in one person’s care, was investigated in retrospect, by us during this inspection and has been commented on in the outcomes ‘choice of home’ and ‘ personal care and healthcare’. Shortfalls were evidenced and feedback was given on these to the Registered Provider during this inspection. These were acknowledged and confirmation given that action will be taken to ensure that they are not repeated. The home’s complaint file was inspected. The Registered Provider explained that there is one resident who frequently brings concerns/complaints to staffs’ attention and that these are recorded in the person’s own file. We suggested Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 19 that these are recorded in the complaints file, even if they are concerns, so that a clear audit of what was done and the outcome can be seen. We saw the complaint procedure on the notice board and on the back of bedroom doors. This contained our address in case people wish to contact the Commission directly. Most of the questionnaires back from service users and their representatives confirmed that people knew how to make a complaint. Only one out of seven received, indicated they did not know how to make a complaint and another knew the process, but would require help to do this, which they felt they would get if needed. We discussed the arrangements in place to protect people from abuse and harm. The home has an extensive policy to help guide staff. The order in which such an event or allegation would be managed, needs reviewing. For example staff should first speak with external agencies such as the police or safeguarding adults team, before ‘in house’ staff begin to interview people and take statements. The Registered Provider assured us that this would be reviewed. We spoke to one member of staff who was aware of the whistle blowing policy and knew how she would use this if needed. She also confirmed that compared with another care home she had worked in, she felt confident that the Registered Provider in this home would act appropriately if required. Staff also receive training on this subject. The Annual Quality Assurance Assessment (AQQA) tells us that staff are due to be trained in the implications of the Mental Capacity Act, which will further help protect those who may require support in decision making and ensuring that their ‘best interests’ are protected. The poor recruitment practice as evidenced in the ‘staffing’ outcome of this report compromises peoples’ safety and requires improvement to avoid further action being taken by the Commission. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from living in a clean, safe and well-maintained home, where they are encouraged to personalise their own living spaces. EVIDENCE: In assessing this outcome the Key Lines of Regulatory Assessment (KLORA) were applied so that a proportionate assessment could be made. We walked around the building and in doing so, visited every bedroom. These were well decorated and contained items required under the National Minimum Standards. Some people with the help of their families had personalised their rooms with their own belongings, others were less personalised. Each room contains an area for washing and a toilet that can be closed off from the main bedroom. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 21 Communal rooms are large and contain a variety of chairs, a television and music centre. The dining room tables were attractively laid at lunchtime. We also noticed that the home was clean and free from offensive odours. There is a rolling programme of decoration and The Annual Quality Assurance Assessment (AQQA) confirms that there is a financially managed rolling programme of redecoration and refurbishment. So far this year this has included redecoration of several bedrooms, replacement of furniture in lounge areas and new windows in the lounges. The home was warm but there was also good ventilation. The grounds are extensive with country views and people spoken to clearly appreciate these. We observed staff wearing protective aprons and gloves as required and they receive training on infection control practice. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Despite staff receiving training there have been some basic shortfalls in care management. The homes recruitment practices do not help to protect residents from people who may harm or abuse them. EVIDENCE: In assessing this outcome the Key Lines of Regulatory Assessment (KLORA) were applied so that a proportionate assessment could be made. It is the potential level of risk placed on people living in the home through poor recruitment practices and the fact that there was a requirement in the previous inspection report pertaining to this that makes this outcome poor. The care staff receive predominantly ‘in house’, training, however, the home is a designated training centre for the social care sector and provides training for care staff from other care services, which at times includes training from external healthcare professionals. Feedback from the staff, both at the inspection and within questionnaires sent to them prior to this inspection, is that they feel there are ample opportunities for training. In relation to the shortfalls identified in one complaint, the Registered Provider agreed that senior staff in particular, require further Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 23 support/training in assessment skills, planning of care and recognising what their responsibilities are in relation to all of this. We were told that there are four care staff on duty in the morning and three, sometimes four, in the afternoons. These numbers include the senior member of staff for that shift. We saw the staff rota and for the next two weeks from this inspection, the afternoons had three on duty. At night time, from 8pm to 8am there are two staff. There are several people that require two people to care for them and others that have specific needs. The building is also on three levels and spread out, so we asked if these staffing levels were considered adequate. One senior member of staff felt they were. The Annual Quality Assurance Assessment (AQQA) tells us that the home does not use agency staff. In addition, a designated member of staff covers the laundry each day. The catering company staffs the kitchen. Maintenance and administration is done by one of the Registered Providers. Both Registered Providers/Owners are present in the home most days. Staff are expected to go onto the National Vocational Qualification (NVQ) and all new staff attend induction training linked to the Common Induction Standards. Currently eight staff have completed their NVQ award and another four are due to start, this includes night staff. We inspected the recruitment records for three staff. The Annual Quality Assurance Assessment (AQQA) tells us that all staff have a check carried out by the Criminal Records Bureau (CRB). This would be correct, but in all three cases the staff had started work in the home before their CRB’s had been returned. To add to the risk, these staff had been employed before a check against the Protection of Vulnerable Adults (POVA) list had been completed. Even if the Registered Provider needed to employ these staff prior to their CRB returning, because the home urgently needed to recruit, the POVA check is crucial to ensure that people who have been reported for being abusive or harmful to is vulnerable adults or children are not employed. One person had been employed with only one reference and another, despite the person being employed by another care home and therefore working previously with vulnerable adults, was accepted on references supplied by care staff colleagues in that home. This is not robust enough; references should be sought from the Registered Manager or Registered Provider. This is to ensure that precise reasons for their leaving that employment have been explored. The management of these recruitment processes do not help to protect people from abuse and harm. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The outcome for people in this home is good in some areas. Other shortfalls, in areas such as recruitment however, will compromise this if left unmanaged. EVIDENCE: In assessing this outcome the Key Lines of Regulatory Assessment (KLORA) were applied so that a proportionate assessment could be made. This care home has been owned by the present Registered Providers for some time and both are actively involved. The current Registered Manager however, seemed confused in her understanding of her role and legal status in the home when we asked her. The Registered Provider explained that this person wished to withdraw from this responsibility but that currently the Deputy Manager was studying for the Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 25 Registered Manager’s Award (RMA). Both the Registered Manager and Deputy Manager agreed that they share the work and responsibility, however there are definite shortfalls that have been identified in this report that the Registered Manager must exert leadership on. The Registered Manager must understand that she holds responsibility for tasks that maybe being carried out by other people, such as the recruitment of staff. Shortfalls were identified in this area in the previous inspection and have been repeated in this inspection. This must improve in order to avoid enforcement action being taken by the Commission. We were informed that staff meetings are not held, but that detailed ‘handovers’ between shifts take place. We would ask the senior management team to reconsider this in view of the evidence in the report, so that a forum can be held where all staff receive the same guidance and feedback. The views of those using the service are sought and information on this was in the main hall. Medication records are audited, but care plans are currently not and this would help identify shortfalls in the general recording and pre admission assessment process. We were informed that the home does not hold any monies for safekeeping. On inspecting recruitment files for three staff, we saw that two of these staff had received supervision earlier this year. The home carry out varies checks to ensure the environment is safe. These include checking the temperature of the hot water supply in order to prevent scalding injuries to older skin. The storage and distribution temperatures in the main tank are maintained at appropriate temperatures so as prevent any outbreak of Legionella. We saw a letter confirming this, dated October 2007. We saw records and certificates that demonstrate that any services directly linked to the main utilities; electricity, gas and oil are serviced regularly. The main boilers were last serviced in November 2007. The electrical installation was last checked in January 2005 and is valid for 5 years. Any equipment used for safe moving and handling is also serviced and checked. An external contractor last checked the hoists in December 2007. The main passenger lift’s service contract was dated up until 31/3/07. Various fire safety arrangements are in place. This included a comprehensive fire risk assessment, due for review in March 2009. The evacuation procedure spoke of the fire services initiating vertical or final exit evacuation, but it also went onto say that this type of evacuation should not be ruled out by the person in- charge. The home had recently purchased a ‘ski mat’ to help with evacuation of non-mobile residents, but staff had not yet received training in its use. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 26 The Fire Safety Officer had recently inspected the home and had made some requirements in relation to door closures and areas that required improved protection from 30 minutes to 60 minutes. We were shown an area where one resident smokes, staff referred to it as the designated smoking area for residents, but we noted that the door between this and the main home was permanently open during our inspection and the smell of smoke could be smelt in the main hall. Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 27 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 2 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 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 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X X 3 X 3 Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 28 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 OP3 Regulation 13(4)(c) Requirement The Registered Manager must not offer accommodation to a service user unless the needs of that person have been fully assessed by a person competent to do so. This would also include service users admitted for respite care. (Timescale of 26/05/06 & 31/03/07 not met). The Registered Manager must ensure that the service users’ assessed care needs, each have a relevant care plan that provides staff with sufficient guidance on how to meet these needs. This would also include the needs of those admitted for respite care. The Registered Manager must review and put systems in place at the home to promote and secure the proper provision for the health, welfare, care and treatment of service users. Timescale for action 31/08/08 2 OP7 15(1)(2) 31/08/08 3 OP8 12 31/08/08 Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 29 4 OP15 17 Schedule 4 (13) 13 (4)(c) 5 OP18 6 OP29 19 7 OP33 24(1) (a&b) The Registered Manager must ensure that a record is kept of the food provided to service users (this relates to sandwiches provided for tea and supper). The Registered Persons must ensure that the home is managed in a way that avoids unnecessary risk to the people living there. The Registered Persons must ensure that all appropriate recruitment checks have been carried out and are satisfactory before a person is employed. This would include satisfactory references, reasons for any gaps in employment history, Criminal Record Bureau (CRB) & Protection of Vulnerable Adults (POVA) clearances. Timescale of 31/03/07 not met) The Registered Manager must improve the quality assurance system so that it helps to identify shortfalls in systems (such as care planning & recruitment) and which provides a timescale in which this is to be completed and evaluated. (Timescale of 1/07/06 & 30/04/07 not fully met). 31/08/08 31/08/08 31/08/08 31/08/08 Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 30 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 2 Refer to Standard OP1 OP32 Good Practice Recommendations Review the system in place that enables people to receive information about the home prior to their admission to see if this can be improved upon for some. General staff meetings should be considered, where guidance can be given to all staff as and when required and subjects that involve everyone can be can be discussed Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Brookthorpe Hall Care Centre DS0000016392.V361387.R01.S.doc Version 5.2 Page 32 - 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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