CARE HOMES FOR OLDER PEOPLE
Brookview Nursing Home Holmley Lane Dronfield Derbyshire S18 6HQ Lead Inspector
Susan Richards Unannounced Inspection on 05 September 2005 at 10:00 am 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 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. Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Brookview Nursing Home Address Holmley Lane, Dronfield, Derbyshire, S18 6HQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01246 414618 01246 291529 Brookview Nursing Home Ltd Ms Sheila Bacon Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. That the increase in beds from 40 to 60 is phased in accordance with the completion of an agreed programmed works to the building - as detailed in the site visit report and letter dated 16.05.05. 2. That no more than 40 service users are accommodated without prior approval of the Commission - dependant on compliance with agreed phased works. Date of last inspection 02.03.05 Brief Description of the Service: Brookview Care Home provides nursing and personal care for up to 60 older persons. The registered person took ownership of the home on 17.07.03 and is currently investing in substantial redevelopment and upgrading of the home and its facilities. Since the previous inspection an application from the provider to increase the number of beds from 40 to 60 has been granted by the Commission in accordance with agreed conditions for its phased development. The Registered Manager has been in post for approximately 18 months. She is a registered nurse and is supported by a team of registered nurses, care and hotel services staff and also has access to external management support. An activities co-ordinator is also in post. Equipment is provided to assist service users with their physical disabilities, both environmental and individual items and there is an emergency call system provided to all areas which service users have access. Visiting to the home is open. Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of this inspection was on the environment, health and safety, and the systems and arrangements for the management and staffing of the home. What the service does well: What has improved since the last inspection?
The registered manager has continued to successfully review and develop the management and staffing systems in the home. This has included the ongoing arrangements for the induction and training of staff and their successful recruitment, which has increased the overall staff compliment. The substantial development and upgrading of the environment is well underway. Staff morale is good. Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 6 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. Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 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 standard(s) The standards in this section were not assessed on this occasion. EVIDENCE: Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 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 standard(s) The standards in this section were not assessed on this occasion. EVIDENCE: Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 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 standard(s) The standard in this section were not assessed on this occasion. EVIDENCE: Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 11 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 standard(s) The standards in this section were not assessed on this occasion. EVIDENCE: Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19, 20, 21, 22, 23, 24 & 25. The upgrading and redevelopment of the home was continuing well with attention given to ensure the safety of all service users, staff and visitors and to minimise disruption to the same. However, the status of the gas dryer in the laundry required confirmation/action as appropriate. Also total completion of Phase 1 of the redevelopment was required in accordance with the conditions of registration as detailed in the site visit report previously forwarded to the registered provider. EVIDENCE: A tour of those parts of the building registered for use was undertaken and discussions were held with the deputy manager, staff and service users/representatives about the active works and upgrading for redevelopment of the home and the impact and arrangements for service users. Service users were not able to sit out in the grounds of the home during the summer due to the substantial on site building works underway. However, records of consultation with them and their representatives in respect of this were seen and were satisfactory.
Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 13 Some service users bedrooms were sampled for inspection, as were bathrooms and toilets and communal areas. All areas within Phase one of the development, which is now occupied by service users, were inspected. Here, all areas were suitably furnished and decorated to a high standard. Some toilets did not have grab rails fitted and one bathroom did not have a wash hand basin provided. There were no light covers fitted to en suite ceiling lights. Work was well underway in Phase 2 of the redevelopment, therefore a full inspection of this area was not undertaken, although some communal areas were seen, which were incomplete at this stage, together with the reception and nursing office. Redecoration and upgrading had begun in Phase 3 of the redevelopment and industrial cleaners and decorators were present. Areas of the home, which were inspected, were clean and free from offensive odours. The provision of heating and lighting and ventilation and the arrangements for the maintenance of equipment in the home, including the hot and cold water systems was inspected and was overall satisfactory. However, a written service report as provided by an external engineer for the gas dryer in the laundry indicated that additional repairs and upgrading were required in order for this equipment to meet with gas safety standards. The deputy manager had no knowledge of this work being carried out and there was no further record to indicate the achievement of this. Written details and recommendations from other officers (fire and buildings control) were briefly discussed with the deputy and also the provision of adaptations and equipment in accordance with the development plan for the home. The laundry was not inspected on this occasion. Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30. There were satisfactory arrangements in place to ensure the provision of sufficient and adequate staffing levels and that staff are properly inducted and trained. Recruitment processes were generally satisfactory, although confirmation had not been received for the applied criminal records checks for two new staff starters. EVIDENCE: The arrangements for staffing provision in the home were discussed and records were examined in relation to these, which were satisfactory. The Inspector discussed the arrangements for staff recruitment, induction and training with the Deputy Manager and three relatively new staff starters. Records were also examined in relation to these. Again these were satisfactory. Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 36, 37 & 38. The registered manager has successfully established recognised systems, which facilitate a consistent approach to the management of the home and promotes the health, safety and welfare of service users, staff and visitors. EVIDENCE: The registered manager was not present on the day of the inspection. The Inspector discussed the arrangements for the management of the home, including systems relating to staffing, communication, quality assurance and quality monitoring and health and safety/safe working practises with the deputy, which were satisfactory. Areas relating to the above were also discussed with individual staff and records were examined, together with some policies and procedures. The practical arrangements for the promotion of health and safety in the
Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 16 environment were also observed during the inspection of the building and were satisfactory. Staff spoken with confirmed their access to a rolling programme for core health and safety training and access to key health and safety policies and procedures and relevant guidance in the home. Records were observed to be safely and securely stored. Comments have been made under the Environment section of this report in relation to the servicing and maintenance of the gas dryer in the laundry. Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x
COMPLAINTS AND PROTECTION 2 2 3 2 3 2 3 x 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 Standard No 16 17 18 Score x x x 3 3 3 3 x 3 3 2 Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP22 Regulation 23(2)(n) Requirement Grab rails must be provided in those toilets in Phase 1 of the redevelopment, which do not have them. A wash hand basin must be fitted in the bathroom on Phase 1 of the redevelopment. New staff must be confirmed in post only following completion of a satisfactory criminal records check. Satisfactory written confirmation must be provided regarding the maintenance/repair status of the gas dryer in the laundry in accordance with the service report requirements. Timescale for action 30.09.05 2. 3. OP21 OP29 23(2)(j) 19(1)(a) & (b) 23(2)(c 30.10.05 immediate 4. OP38 (& 19) 05.09.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP26 Good Practice Recommendations A rollator iron should be provided in the laundry. Brookview Nursing Home C52 C02 S2046 Brookview Nursing Home V247633 050905 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby, DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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