CARE HOMES FOR OLDER PEOPLE
Brookwood Residential Home 12 - 14 Greenfield Lane Balby Doncaster South Yorkshire DN4 0PT Lead Inspector
Tony Railton Key Unannounced Inspection 18th July 2007 08:30 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 Brookwood Residential Home DS0000065011.V345480.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. Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Brookwood Residential Home Address 12 - 14 Greenfield Lane Balby Doncaster South Yorkshire DN4 0PT 01302 310295 01302 853518 NONE 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) Atheray Organisation Limited Mrs Rosemary Jane Winifred Sharp Care Home 30 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (14) of places Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th July 2006 Brief Description of the Service: Brookwood provides personal and residential care for up to 30 older people, 16 of who may also have Dementia. The two Victorian semi-detached houses provide 24 single and three double bedrooms. The home provides two dining rooms, two lounges and a quiet room and there is also a passenger lift. There is garden to the front and rear of the home, part of which is enclosed for the safety of people using the service. Situated in the Balby area of Doncaster. It is close to local shops, a church, a library, public house and other local facilities. On 18th July 2007 the providers said the range of fees are £380.62 and £410.15 per week. Items not covered by the fee include newspapers, hairdressing and private chiropody. Further information about the services provided and the role of the CSCI can be obtained from the home. Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced visit to the home started at 08.30 and ended at 13.00.During the visit there was the opportunity to meet and speak to people using the service, the manager, carers, kitchen and domestic staff. A sample of six peoples records were seen and included assessments, care plans, reviews, daily and medical records. A sample of staff records were seen and included references, police checks training and supervision records. The medication administration systems were checked and a tour of the home was undertaken. Other information considered included the homes Annual Quality Assurance Assessment and the returned relatives, (5) and residents (9) quality assurance surveys. This was a very positive visit where a number of improvements were noted. The inspector would like to take the opportunity to thank the people using the service, the manager and her staff team for their patience and positive contribution throughout the visit. What the service does well:
There is a relaxed and homely atmosphere created and people using the service were seen to be comfortable and happy. One person said that they have lived in the home for eight months and that the staff are “fantastic”, and that they have “never had a bad meal yet”. One relative reported that they had a few bad experiences at other homes and that they were “pleased to have come across Brookwood”. “The manager and staff make me feel confident in the care they are giving.” “I can see my relative is being well treated and given the dignity they deserve”. “I feel they are safe, comfortable and well cared for”. “All the staff and residents come across as a team, in a very caring and calming way”. “Nothing is to much trouble and my family and I are made to feel very welcome”. People using the service are cared for and have their needs met by trained and qualified staff. People were observed throughout the visit being asked what they would like to do and their choices respected. Positive relationships were observed being fostered between people using the service and those caring for them.
Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 6 Peoples’ personal and healthcare needs are met in a relaxed and unhurried manner, and people are protected and safeguarded by the policies and procedures used by the service. What has improved since 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. The summary of this inspection report can be made available in other formats on request. Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 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 Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 To make sure the service can meet peoples personal and healthcare needs, these are assessed before they are admitted. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: To make people receive the care they need a sample of six peoples’ records show that they have their personal and healthcare needs assessed before they are admitted. The records show that most people already have an assessment of their needs completed by the Social Services Department of Health Services. Discussion with the manager found that the home does not provide specialist rehabilitation services for those requiring intermediate care. Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People are protected by the way medicines are dealt with and the care they need is set out in their own individual care plans. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: A sample of six peoples records show that their care needs are assessed and that their needs are planned for and met by the service. Records also show that the care plans are reviewed and people and their relatives have the opportunity to comment on the service and to sign to say they are happy with the care provided. People are supported by ordinary healthcare services, which include Chiropodists, Opticians and Dentists. The medical records confirmed this. Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 10 The senior carer said that the medication system has changed and is much safer, and that all staff that administer medicines have received advanced training to make sure medicines are given safely. The medication system was checked and found to be safe. A sample of five peoples medicines were checked and found to be correct. Observation of two medicine rounds found that people are protected as medicines are given correctly and safely. Throughout the visit people were observed being treated with dignity and having their wishes respected. One relative said that they “can see their relative being well treated and given the dignity they deserve”. Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 11 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 and 15 People using the service find that the lifestyle experienced in the home matches their expectations and that they are assisted to exercise choice and control over their lives. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: Discussion with people using the service found that they are happy with the care and meals provided. The returned relatives and residents’ quality assurance surveys confirmed this The record of activities show that people enjoy a range of activities that are organised on a regular basis for people to join in if they so wish. One person said that they like the “Sing-a-long’” and in particular “singing through the microphone”. People were observed enjoying breakfast and lunch in a relaxed and unhurried manner and in pleasant and comfortable surroundings.
Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 12 One person said that they “have not had a bad meal yet”. Another said that the “meals are very good” and that they have a “choice”. The menu checklist confirmed this and people were observed being offered and exercising choices and preferences. A sample of the lunchtime meal found it to be well presented, well cooked and tasty. The menus show that people are offered a varied and balanced diet. Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 13 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 and 18 People are protected by a robust and accessible complaints policy and procedure and are safeguarded from any kind of abuse. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: Complaints from people using the service and their relatives are dealt with properly. This was confirmed by the manager and by the record of complaints and annual quality assurance assessment records. The five relatives and nine residents quality assurance surveys show that they know how to make a complaint but that they have never had to. One person said that they have been in the home for eight months and that they have “never had any reason to complain about anything.” To protect people using the service all staff have received POVA, (Protection of Vulnerable Adults) training, this was confirmed by the manager, care staff and the staff training records. Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 14 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 and 26 People live in a home, which is comfortable, clean and safe. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: One person said that they “like living in Brookwood”, it is “homely” and there is a “nice atmosphere”. Another said that “its great”, “I’ve got everything I need”. People were observed throughout the visit relaxing in the lounges, dining rooms and bedrooms, which are clean, well decorated and well maintained. A number of improvements for people using the service were noted and included re-decoration and new floor coverings provided in the toilets and bathrooms.
Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 15 People did not have access to one of the dining rooms’, which was closed due to water damage. The manager said that the dining room is going to be decorated and provided with a new floor covering and dining room furniture. The homes development programme and annual quality assurance records confirmed this. Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 16 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 and 30 People’s needs are met by experienced and qualified staff and are protected by the staff selection and recruitment practices. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: People using the service are protected by the way staff are recruited as staff records show that references and police checks are taken up before they are employed. People have their personal care needs met by staff that are trained and qualified. As discussion with the manager, the training matrix, the staff records and annual quality assurance documents show that all staff with the exception of two have a NVQ National Vocational Qualification at Level 2 or above. One person using the service sad that the staff are “wonderful” and that they are “very caring”. One relative writes “all the staff come across as a team in a very caring and calming way”. Another writes “the manager and staff make me feel confident in the care they are giving”. “I can see my relative is being well treated and given the dignity they deserve”. “I feel they are safe, comfortable and well cared for”.
Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 17 “Nothing is to much trouble and my family and I are made to feel very welcome”. Throughout the visit people’s needs’ were observed to be met in a relaxed and unhurried manner and positive relationships being fostered between people and those caring for them. Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 18 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 and 38. People live in a well managed home that is run in their best interests. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. EVIDENCE: Records show that the manager has a Registered Managers Award, NVQ Level 4 and is qualified to run the home. The manager confirmed this. The minutes of the residents and staff meetings show that they have the opportunity to comment on the running of the home. The five relatives and nine residents quality assurance surveys show that people and their relatives have the opportunity to comment on and have a say about the quality of the care provided by the service.
Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 19 Peoples’ financial interests are safeguarded as records show that the manager carries out a monthly audit and three peoples monies were checked and found to be administered correctly. It was noted, however, that due to the way the keys are administered, people using the service and their relatives do not always have immediate access to their monies. The health, safety and welfare of people using the service is promoted as records, including staff training records show that they receive, First Aid, Moving and Handling, Health and Safety, and Infection Control training. To make sure people are safe records show that staff receive appropriate Fire training and that a proper record is kept of Fire Tests and drills. Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 20 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 3 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 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP14 Good Practice Recommendations The daily records would benefit from an increase in the use of descriptive words to reflect and show peoples choices and preferences and any decisions they make about the way they live their daily lives. The remedial work needed in the second dining room should be carried out as soon as is practicable. A protocol should be developed to make sure that people using the service have access to their monies at all times. 2 3 OP19 OP35 Brookwood Residential Home DS0000065011.V345480.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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
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