CARE HOMES FOR OLDER PEOPLE
Brookvale Lawn 15 Lawn Road Portswood Southampton Hampshire SO17 2EX Lead Inspector
Lorraine Parton Unannounced Inspection 13th March 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Brookvale Lawn Address 15 Lawn Road Portswood Southampton Hampshire SO17 2EX 023 8057 7786 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) Brookvale Homes Limited Mrs E Raison Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: Brookvale Lawn is one of a number of residential services owned by the same proprietor. Brookvale Lawn predominately provides a service for older persons who have some degree of age related frailty. The home is a modern purpose built residential building situated in a residential area of Southampton, close to the local amenities of Portswood and a short ride away from Southampton City Centre. The home is staffed twenty-four hours a day by care staff and there is also a team of domestic and catering staff. The accommodation is organised over three floors, which are all accessible by a regularly serviced passenger lift. All bedrooms are designed for single occupancy, however an extra room is provided for couples or residents wishing to share. The home has a communal lounge and dining room and each level has a good size lounge and in addition the home has a chapel and hairdressing facilities. L Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over five hours. The inspector audited ten standards and reassessed four standards, in respect of which requirements had been made at the last inspection. It is evident that the home is providing a very good service for the residents. The inspection involved a walk around the home and an audit of some documentation, which was found to be good. The registered manager and one of the home’s staff assisted the inspector. The inspector had the opportunity to speak to several service users during the inspection, all of whom praised the staff and the service they receive. What the service does well: What has improved since the last inspection?
The home has reviewed service users care plans to detail how specific needs are being met and to ensure for anyone on ‘as required’ medication this is clearly documented in their plans. The home was able to provide evidence that all equipment and safety systems are maintained and serviced as required.
Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 6 The inspector looked at two staff files, one of which was for a new member of staff. Both files were found to contain all relevant information. On discussion with the manager it was clear that she was aware of recruitment procedures. This had been a requirement at the last inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were no inspected on this occasion. EVIDENCE: Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 All service users have a clear care plan. Medication practices are safe. EVIDENCE: The home has reviewed most of their care plans since the last inspection to take account of how they manage specific care issues. This had been a previous requirement. Care plans were found to be satisfactory. The home had incorporated into the service user plans instructions for staff on how to manage ‘as required’ (prn) medication. This had been a previous legal requirement. All prn medication was clearly documented on the medication recording sheets. Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Service users confirmed that the home provides excellent food of their choice. EVIDENCE: Service users spoken to stated that the home provides good food and offers a choice of menu. Menus indicate meals are well balanced and nutritious, which, the staff stated are based on service users requests at meetings held within the home. Service users confirmed this. Individual choices and needs in food are catered for and this includes likes, dietary needs, vegetarian, and special requests. At the time of the inspection the home offered two choices in the main meal, and service users confirmed that the home always offers alternatives. Service users confirmed that the home always meets their specific choices. Meal times were noted to be relaxed. All staff involved in food preparation are fully trained and the home has a chef who was fully aware of food safety risks. Food safety records were being kept and found to be satisfactory. All food storage and preparation areas were maintained to a high standard.
Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 11 The previous inspection in September 05 identified that standards 12, 13 and 14 were met. Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: None of the standards were assessed on this occasion. The previous inspection in September 05 indicate that standards 16 and 18 were met. Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The home provides a safe environment for service users to live in. The home has adequate procedures for the control of infection. EVIDENCE: The inspector audited all the homes records for maintenance of equipment, which all were found to be up to date. The inspector audited the following records; gas, electrics, portable appliances, white goods, fire equipment and lifts and moving equipment. The home has completed a range of risk assessments, however, the controls were vague and did not always include the controls implemented by the home and in line with the homes policies. The inspector gave the home’s staff advice on completing suitable risk assessments. The home is required to review its risk assessments. Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 14 The home has a infection control policy and procedures, which were found to be adequate. Several staff have received training in the prevention of cross contamination. Any soiled laundry is managed in accordance to the homes policies and procedures and staff wear appropriate protective clothing when necessary. Chemicals are stored in appropriate storage areas. All areas of the home were clean and free from odours. Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The home had adequate staff on duty to meet service user needs. Service users are safe. The home has suitable recruitment procedures in place for the employment of new staff. Staff receive extensive training, however, the home does not have 50 of staff trained to NVQ 2 level. EVIDENCE: At the time of the inspection four care staff and the manager were on duty. The home also had two kitchen staff, a person dealing with laundry and a cleaner on duty. The home was providing accommodation for twenty five service users and the staffing level seemed appropriate to the needs of the service users by the inspector. Staff were seen with service users and interacting in an appropriate manner. Service users confirmed that they felt safe in the home and that the homes staff are always supportive and professional in their approach. Two staff files were audited by the inspector and found to contain all the relevant information. This included application forms, contracts and job descriptions, interview records, references and CRB and/or POVA checks for
Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 16 new staff. Staff files also contained training and induction records, supervision notes and appraisals that had been carried out. The inspector had the opportunity to speak to one member of staff who confirmed that they had received an induction into the home. Staff were observed to be committed to providing a high quality of care and service for the service users. Staff confirmed that they receive training relevant to the service users’ needs and that the homes manager supports training requests. On speaking to the homes manager it was ascertained that the home employs eighteen staff and five staff have completed either the NVQ 2 or level 3 training and three staff are currently undertaking the course. This leaves a small deficit of meeting the target of 50 of the team being trained to NVQ2. A requirement has been made. Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 17 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): 33, 35, 36, 38 Service users are consulted about the running of the home, however, this needs formalising. Service users money is safeguarded by adequate financial record. Staff are supervised and appraised within their jobs. Service users and staff are protected by the homes health and safety policies and procedures, however, these need developing to ensure all controls are documented. EVIDENCE: The home does hold service user meetings, which the inspector was able to see the minutes for. Comments in the meetings were positive and any requests are acted upon. The home has started to ensure questionnaires are
Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 18 undertaken by service users and visitors to the home, however, the systems for the monitoring of quality has not been formalised to ensure all stakeholders views are taken into account. The home is currently developing their systems and it was agreed that they would ensure their questionnaires would take into account the views of other stakeholders of the business. This should include visitors, healthcare professions, and staff. The home has been advised that they will need to produce a yearly report for CSCI completed after seeking the views of all stakeholders. The service users or their families manage their own finances. The home keeps some service users’ personal money in the safe. All records were maintained for any money received or spent. The home completes staff supervision on a regular basis. Staff confirmed that they receive supervision from the home manager and that they find these useful to their roles and responsibilities. Staff confirmed that they have meetings and that these meetings enable them to speak openly. Staff confirmed that the manager keeps them informed of any changes. Staff felt that communication between the staff was very good. The home has undertaken an extensive range of risk assessments, including service users own risks, the environment, specific staff roles, and for the equipment used within the home. The home has implemented controls - for example for identified risks including radiators, hot water, chemicals, falls, moving and handling and the outside of the home, however, the documented controls appear vague, do not always cover all the controls in place and are not consistent with the homes policies and procedures. All staff have received training in health and safety, including moving and handling, infection control, food safety. The home has implemented maintenance and relevant checks for all controls in the home. The home has its own maintenance staff who work in the home on a daily basis. All certificates and servicing records were up to date. The previous inspection in September 05 identified that standard 31 was met. Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 19 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 Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 20 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP28 Regulation 18 Requirement The home must ensure that they are working towards 50 of the staff team are trained to NVQ level 2. Develop and formalise the quality monitoring systems in the home. This must include consultation with service users and other stakeholders of the business. The home must provide a yearly report to CSCI. Review all the homes risk assessments and ensure the controls reflect the homes policies and practices. Service user risk assessments should be incorporated into service user plans. Timescale for action 30/04/06 2 OP33 24 30/04/06 3 OP38 13 30/04/06 Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 22 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 Brookvale Lawn DS0000011776.V253430.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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