Inspection on 07/03/07 for Brookvale Lawn

This inspection was carried out on 7th March 2007.

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

Brookvale Lawn 13/03/06

Brookvale Lawn 20/09/05

Brookvale Lawn 14/02/05

Brookvale Lawn 25/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Brookvale Lawn 15 Lawn Road Portswood Southampton Hampshire SO17 2EX Lead Inspector Jan Everitt Unannounced Inspection 7th March 2007 09:30 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.V328067.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. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 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.V328067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th March 2006 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 mental 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. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit to Brookvale Lawn, which was unannounced, took place over a one day period on the 7th March 2007 and was attended by one inspector. The visit to Brookvale Lawn formed part of the process of the inspection of the service to measure the service against the key national minimum standards for the year 2006/7. The focus of this visit was to support the information gathered prior to the visit. The judgements made in this report were made from information gathered prior to the visit; pre-inspection information submitted to the commission by the registered manager, information from the previous report, the service history correspondence and contact sheets appertaining to the service were also taken into consideration. A number of comment survey cards were sent to relatives prior to the visit of which five were returned. They were generally very positive about the care and services and were taken into consideration when formulating the judgements. Owing to the mental frailty of a number of service users the comment survey cards were not received back. Survey comment cards were also sent to other stakeholders, of which none were returned. Further evidence was gathered on the day of the site visit. The manager and deputy manager assisted the inspector throughout the visit. The inspector toured the building and spoke with a number of the residents, relatives and also spoke to staff. A sample of records was also viewed. What the service does well: The manager has a great deal of experience of managing a care home and as a consequence is able to thoroughly assess service users before they are admitted to the home to ensure the home can meet their needs. The care planning system is comprehensive and details how service users prefer their care and activities of daily living to take place. The relatives returned positive comments to the inspector about the services and care received in the home. ‘They support my sister to live in comfort and attend to her needs’. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 6 ‘Reassured that my father is looked after at the age of 95’. ‘It is evident that they are kind and caring and see to the needs of the residents’. ‘Very helpful staff and manager’. ‘The home is doing everything I would expect’. ‘Everything is good in the home’. ‘My mother’s health has improved since moving into the home’. ‘My mother is very content with her life in the home’. The environment of the home is clean and well maintained and service users and their relatives are satisfied with the standard of cleanliness and comment, ‘the place is spotless’. The provider is investing in the refurbishment and replacement of fixtures and fittings on the complete ground floor, work for which is about to commence. The home provides a wholesome nutritious diet that service users and relatives comment as being ‘good and well presented’. What has improved since the last inspection? What they could do better: The medicine trolley must be secured and stored safely in an appropriately locked environment. The manager must ensure that the home’s recruitment practices are more robust and that relevant information is sought and recorded prior to staff commencing their employ. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 7 The infection control policy must be reviewed to ensure it reflects the practices that take place in the care home. The weights and nutritional status of the service users should be recorded to ensure that risks are identified. 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. Brookvale Lawn DS0000011776.V328067.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 Brookvale Lawn DS0000011776.V328067.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures it can appropriately support and meet the needs of prospective resident by undertaking a thorough assessment prior to them moving to the home. EVIDENCE: The inspector viewed a sample o resident’s personal files. The files demonstrate that the manager and her deputy undertake a thorough assessment of prospective service users prior to them moving into the home, to ensure the home can meet their needs. The manager reported that relatives are encouraged to be involved with this assessment and in many cases they are. She also told the inspector that it is the relatives that usually visit the home prior to any decisions being made about the person moving in. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 10 The manager spoke of the difficulty of sometimes obtaining information from care managers and from the clinical areas. However information is obtained from relatives and other professionals such as community psychiatric nurses (CPN) and GP when required. The inspector spoke to relatives visiting the home who reported that they had visited a number of homes in the area and could not believe ‘how lucky we were to find this place, it is excellent and we were fully involved with mother’s admission to this home’. Another relative informed the inspector that she had ‘visited seven homes in the area and this was by far the best’. Brookvale Lawn DS0000011776.V328067.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 good. This judgement has been made using available evidence including a visit to this service. The home works well to meet and respect the residents’ health and welfare needs through the care planning process and links with health care professionals. The policies and procedures for the storage of for the management of medication need reviewing. Service users are treated with respect and their privacy upheld. EVIDENCE: The inspector viewed a sample of four service user’s care plans. They demonstrated that all the information about the service user is recorded appropriately. In addition to personal contact and financial information held on the residents, the home has in place for each service user, care plans that Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 12 have been developed from the assessment documentation. These describe in detail the needs of the residents in terms of support with personal care and their health and welfare needs. There is evidence of care plans being regularly reviewed by the senior carers, and where possible the resident. The daily record of the residents and the outcomes of the care are recorded in the daily notes in detail. There was also evidence that service users, if they are able, sign care plans as evidence of their agreement and participation. The home undertakes risk assessments on service users where there is an area of concern to their health and welfare. These were evidenced in the care plans. The managers informed the inspector that they continuously review and assess risks and the needs of the residents and will support them accordingly. The home is fully supported by the primary health care professionals. The community psychiatric nurse visits the home to administer an injection to one of the service users. The manager reported that there is no provision for a dentist to visit the home and relatives are relied upon to take their relative to the community dentist. The home has a service from a local optician and also a chiropodist visits the home frequently. Service users spoken to and also the visiting relatives remark that they are pleased with the health and social care they receive. A response comment received from a relative said: ‘my mother’s health has improved since moving into the home and I am contacted immediately if they consider she needs to see the doctor’. Owing to a number of service users’ mental frailty it was difficult for the service users to communicate their level of satisfaction with the services delivered in the home and whether their health care needs were met fully. The inspector met with the community pharmacist, who was undertaking an audit of medication in the home at the time. She reported to the inspector that she had found the MAR sheets had been recorded appropriately. She had recommended that a drug fridge be purchased for the storage of those medicines that must be stored at a low temperature. The deputy manager undertook to investigate this purchase immediately. The inspector observed that the room used to store the medicine trolley was also used by the hairdresser on her visits to the home, and at which time the door would remain unlocked. The inspector observed that the medicine trolley was not fixed to an inner wall and just pushed up against a wall. If, when the hairdresser was using the room and the door was unlocked, this would leave the medication trolley vulnerable and the risk of medicines being exposed to Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 13 being taken unlawfully. This was discussed with the pharmacist and manager and it was agreed the medicine trolley must be stored away safely. The inspector discussed with the manager that the medication policy and procedures were dated 1998 and should be reviewed to reflect current practice. The policy should also include the management of covert administration of medicines. Service users are supported to maintain their own medicines and this is undertaken within a risk assessment framework. There were no service users wishing to manage their own medication. The manager told the inspector that the staff that administer medication have received an accredited training from the local college and there is now a new training package available from the pharmacist which she intends to use. The inspector observed that the staff on duty at the time of this visit were interacting well with service users and treating them with respect. There was a good deal of exchange between service users and staff and staff were familiar with the resident’s needs. Service users comments indicated that they were very happy living at the home and felt their privacy was respected. Comments such as ‘my privacy is important to me and is always taken notice of’’ ‘I get as much privacy as I want’. ‘I think I probably do get my privacy respected’. ‘ Within my own room I can do as I wish’. This was supported by a response comment from a relative who wrote: ‘my mother is dealt with in a kind and considerate way’. ‘my mother has arthritic hands and has been given special cutlery and plate at meal times to assist her to be independent with her eating’. Brookvale Lawn DS0000011776.V328067.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. The home considers the individual lifestyles of the residents and supports residents to maintain links in the community and with family and friends. Service users are supported to make choices in their daily lives. The home provides the service users with wholesome, nutritious meals that can be taken in the environment of their choice. EVIDENCE: The manager told the inspector that the activities organiser left the home and she is in the process of recruiting another. The staff try to continue with activities on a daily basis with board games, quizzes and cards. A person from the community visits the home frequently to assist with arts and crafts. The inspector observed this taking place on the day of the visit and noted that there were a considerable number of residents taking part. The inspector Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 15 observed the various arts and crafts pieces throughout the home that had been produced by the residents. The inspector evidenced in the care plans good social histories that had been recorded for each service user. The manager told the inspector that the home tries to accommodate all the interests of the service users and tailor their activities around this information. The manager reported that one resident has his own laptop computer and enjoys going onto the Internet. The inspector viewed the visitor’s book that demonstrated the home has a considerable number of visitors each day. Visitors spoken to by the inspector confirmed that they are made very welcome and that they visit their relative very often. During this visit one resident informed the manager that she would be out to lunch and the manager told the inspector that families often come to take their relatives out. Service users have the freedom and choice to come and go whenever they wish. Those who wish to go out are risk assessed before they can go alone. Another resident goes out frequently in his electric wheelchair to the local shops. Service users spoken with confirmed that they have choices within their daily activities of living. Comments from service users on the survey cards said: ‘The home is quiet and I go to bed when I want to.’ ‘They respond to the alarm call immediately’. ‘The staff are excellent and respond to my requests’. Relative’s comments in the returned survey indicated that: ‘there is entertainment some afternoons which keeps them occupied’. The inspector visited the kitchen and spoke to the cook whilst she was preparing lunch. The kitchen was clean and well organised. The cook said that she and the manager discuss menus and she is aware of the service users’ preferences and creates the menus around this. The inspector noted all fresh vegetables had been prepared for lunch. The manager had submitted a four- week menu plan with the pre-inspection document. Menus indicate, that although there is no choice at lunchtime, the meals are well balanced, nutritious and varied, which, the staff state, are based on service users requests, usually voiced at resident’s 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. Service users confirmed that the home always offers alternatives if requested. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 16 The inspector observed the lunchtime meal and the meal looked appetising and was presented well. Service users appeared to be enjoying their roast dinner. Those spoken with confirmed that the food is ‘ cooked and presented well’. The relatives also told the inspector that the meals were excellent and that their mother, although reluctant to eat and needed prompting to eat, did manage some diet, and chose meal times to visit the home to feed and encourage her to eat. The inspector observed that carers were sitting down with the service users who needed assistance with their eating, and were assisting them to eat in a courteous manner and interacting with them well. Meal times were noted to be relaxed and taken in a pleasant dining area. All staff involved in food preparation are fully trained and the home has a cook who was fully aware of food safety risks. The inspector discussed nutritional risk assessment with the manager, who reported that they are not undertaken routinely but if they are worried about a service user the GP will refer them to the dietician. A recommendation will be made around these findings. Brookvale Lawn DS0000011776.V328067.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 good. This judgement has been made using available evidence including a visit to this service. The home provides an environment where residents, relatives and visitors feel confident that their complaints and concerns are listened to and acted upon. The home as far as feasibly possible protects residents from risk of potential abuse. EVIDENCE: The complaints procedure demonstrated that the NCSC name being displayed on the copy of the procedure sent to the CSCI. This was discussed with the manager and will be reviewed and altered immediately. The home has not received any complaints since the last inspection. Service users spoken to, reported that they would speak to the manager or deputy should they wish to complain. A response comment from a relative confirmed that they had received an information sheet about complaints. Staff comments also confirmed that they would refer any complaints to the manager or deputy manager to deal with. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 18 The adult protection team has investigated one incident of adult protection. This was discussed with the manager. The manager followed the adult protection procedure and showed the inspector the records of events and the minutes of the meeting, which recorded the investigation and resolution to the allegation. The staff are aware of the adult protection procedure and the training for this is part of the induction programme. The manager and some staff, with whom the inspector spoke with, stated that they had received training in protecting vulnerable adults and were aware of the policy and procedures to follow in the event of witnessing or suspecting an incident of abuse. This was confirmed in the staff surveys returned to the inspector and staff were able to describe the appropriate procedures should they wish to report abuse. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 19 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, homely environment that is well maintained. EVIDENCE: The inspector toured the home throughout. The environment was clean and warm. Service user surveys made comments such as the home is: ‘spotless’ ‘Always appears clean’. ‘Could do with a bit more dusting’. The results of the survey were discussed with the manage and she told the inspector that she is addressing any issues raised in the survey and is in the process of recruiting another staff member for housekeeping. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 20 Comments from relatives about the environment were positive and the comments made on the returned surveys were that the home is always clean and tidy, one commenting ‘it is always spotlessly clean’. The home is large and accommodated over three floors, the ground floor provides communal facilities, which is spacious, bright, airy and tastefully decorated. On each floor the home has its own lounge, which again has been tastefully decorated and furnished with high quality furnishings, these rooms provide a pleasant view of the local community and the river Itchen. In addition the home has a chapel, hairdressing facility and library. The manager told the inspector that work is about to commence on the whole of the ground floor communal areas and furnishing and carpets are to be replaced once the decorating has been completed. The home does employ a maintenance man who is shared between the other homes in the group. The manager reported that he visits the home to do the day-to-day jobs that arise. Rooms are redecorated when the room becomes vacant and the resident has occupied if for more than one year. The inspector viewed a number of the residents’ bedrooms and found these to be personalised reflecting the residents history and personality. Again the bedrooms are very nicely decorated and furnished with very good quality furnishings. All bedrooms are fitted with en suite toilet and hand washbasin facilities. A service user told the inspector that she had ‘a lovely room’. The home has the facilities for couples with adjoining doors to a number of rooms, thus allowing the couple to have one room as a bedroom and the other as a lounge if the couples so wished. These rooms also share a balcony. These facilities were not being used at the time of this visit. The inspector noted that a number of service users used the balcony as a garden and plant pots displayed lovely spring flowers. A gentleman said that, although his neighbour did the planting he thoroughly enjoyed the results of her labour and indeed their shared balcony was a picture of spring bulbs. The home has an infection control policy and procedures and describe the procedures to carry through in a more clinical area. The inspector discussed these with the manager. It was identified that these should be reviewed to reflect more home specific policy and procedures and to give a more ‘reader friendly’ guidance to staff for their daily practices within a care home. The policy did not give guidance on the management of soiled laundry, which should be part of the policy for the home. The inspector also identified that a bar of soap was present in the toilet next to the lounge. This should be replaced with a soap dispenser and paper towels Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 21 readily available. The manager said she would ensure that the dispenser was in place by the end of the day. Brookvale Lawn DS0000011776.V328067.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 adequate. This judgement has been made using available evidence including a visit to this service. The home is staffed in sufficient numbers to meet the needs of the current service users. The homes recruitment practices are not robust to ensure that service users are protected. Staff are trained to do their jobs. EVIDENCE: At the time of this visit the home was not fully occupied and was accommodating twenty-four residents. The manager submitted to the CSCI three weeks staff rotas. The rotas did not easily identify the numbers and roles of staff on duty. On the day of this visit the manager reported that she and the deputy were on duty and three other care assistants. One person was off sick. There was one domestic, a cook and kitchen assistant and a designated laundry person. At the time of the visit the home was able to demonstrate that it employs enough staff to cover all areas of the home at all times of the day. This was demonstrated by the service users comments that the alarms are responded to Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 23 quickly and that on the day of this visit staff were not rushing about as though under pressure, which was an indicator that sufficient staff were on duty to meet the needs of the service users. The managers’ informed the inspector that on a typical morning they would have three carers, one senior and the manager on duty, a carer on each floor and the senior floating to offer support. A similar rota is adopted for the afternoon and evening and there are two waking night staff. The pre-inspection document reported that the home employs 16 care workers of which six have NVQ level 2 and above and that six more are in the process of undertaking this training. The manager told the inspector that the provider funds training but the carers do this in their own time and she is in negotiations with the provider for her to hold a training budget and for the training to be fully funded. The mandatory training is funded and provided by an outside organisation. The deputy is a trainer for moving and handling and is about to go on the twoday refresher course. Evidence of training was found in the staff personnel files. At the time of this visit one member of staff was on induction and was being supervised. The home’s induction is based on the Skills for Care Council standards and the programme takes approximately eight weeks to complete. Staff files also contained training and induction records, supervision notes and appraisals that had been carried out. 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. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 24 A sample of three personnel files was viewed to assess recruitment practices. The inspector could not evidence any references for a carer who had recently been employed. This was discussed with the manager and she reported that the carer is being shadowed continually and that she was chasing the written references. The inspector also observed that in another personnel file a copy of the passport for a foreign worker was not present and there was no evidence to state her legality in this country or under which permit she had gained entrance. Staff surveys received indicated that they are satisfied with their terms and conditions of contract and are happy working in the home. One survey commented that: ‘The manager really works around worker’s problems and families and have input into the rota planning’. ‘Workers are given very good free meals’. The recruitment practices of the home are not robust and a requirement will be made from these findings. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 25 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, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a stable management team who are skilled and competent to undertake their roles and responsibilities satisfactory. The home provides a safe environment for residents to live in and staff to work in. EVIDENCE: The registered manager has been in post for seven years and the deputy manager for considerably longer. The manager and the deputy manager have Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 26 undertaken their NVQ level 4 in care and are in the process of doing their Registered Managers Award. The inspector established through the course of the inspection, through observation and discussion that the manager and deputy manager work well as a team, share responsibilities equally and have an open and inclusive approach to staff and residents. The manager stated “the door to the office is always open so I am aware of what’s going on and to allow both staff and residents and their visitors to come and speak to me when they want”. Indeed, this was demonstrated on the day of this with service user’s communicating freely with the management staff. The home has started to ensure questionnaires are undertaken by service users and visitors to the home and now include other stakeholders such as GP. District Nurses, Chiropodist etc. Comments on the surveys state: ‘Very friendly and helpful staff’. ‘Good with communication and contact’ ‘Good at contacting relatives’. The GP commented ‘I feel very well supported’. ‘Nothing is too much trouble. The manager reported that 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 and their environment, specific staff roles, and for the equipment used within the home. These have been reviewed since the last inspection as required from the last report. All staff have received training in health and safety, including moving and handling, infection control, food safety. This was evidenced in the personnel files and the manager had a register of what training had been undertaken and who had attended each of these training sessions. The inspector discussed with the manager how a training matrix to identify who, what and when training took place would give her easy access to information on what training each member of staff had undertaken and when their update was due. This will be a recommendation of this report. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 27 The inspector viewed the fire log and this had not been recorded regularly. This was discussed with the manager who said she would ensure the maintenance man was reminded to record when alarms were tested. A sample of servicing certificates for systems and equipment was seen by the inspector and were observed to be current. The Environmental Health Officer visited the home in June 06 and the report did not make recommendations. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 28 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 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 29 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. Standard OP9 OP29 Regulation Reg 13 (2) Reg 19(1) Sch. 2 Requirement The registered person is required to provide facilities for the safe storage of medication. The registered person is required to ensure that the information to be maintained and recorded in respect of employees as stated on Schedule 2 must be in place before commencement of employment. Timescale for action 30/04/07 30/04/07 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 OP15 OP26 Good Practice Recommendations It is recommended that service users be weighed on admission and nutritional risk assessments undertaken. It is recommended that the infection control policy be reviewed to reflect the day-to-day practices within a care home. Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Brookvale Lawn DS0000011776.V328067.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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