Inspection on 23/01/08 for Brookwood EMI Home

This inspection was carried out on 23rd January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Brookwood EMI Home 07/01/09

Brookwood EMI Home 18/07/07

Brookwood EMI Home 18/07/06

Brookwood EMI Home 30/01/06

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Brookwood Residential Home 12 - 14 Greenfield Lane Balby Doncaster South Yorkshire DN4 0PT Lead Inspector Key Unannounced Inspection 09:15 23rd. January 2008 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.V355693.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.V355693.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 None Atheray Organisation Limited 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) Mrs Rosemary Jane Winifred Sharp Care Home 28 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (3) of places Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (3) and Dementia - Code DE (25) The maximum number of service users who can be accommodated is: 28 18th July 2007 2. Date of last inspection Brief Description of the Service: Brookwood provides personal and residential care for up to 28 older people, 25 of who may also have dementia. The two Victorian semi-detached houses provide 28 single bedrooms. It is situated in the Balby area of Doncaster. It is close to local shops, a church, a library, public house and other local facilities. The home provides two dining rooms, two lounges and a quiet room. Access between the floors is through a passenger lift and staircases. There is a garden to the front and rear of the home, part of which is enclosed for the safety of people using the service. On 23 January 2008, the range of fees charged by the provider were between are £410 and £450 per week. Items not covered by the fee included newspapers, hairdressing and private chiropody. Further information about Brookwood and its services can be obtained from the home. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. Although we have rated this service as adequate, we noted that it has good potential to improve. The owner and the registered manager visited CSCI after the inspection and were both keen to demonstrate improvement. This key unannounced inspection was carried out on 23 January 2008, starting at 09.15 hours and finished at 18.30 hours. There were 23 people in residence at the time of this inspection, 20 of whom had dementia. The registered manager was not present at this inspection. The deputy manager, Ms Kelly Holbrery, was in charge of the home. The inspection included a tour of the premises, examination of care documents and records relating to medicines, complaints and the staff employed at the home. We spoke to three people who live at the home, four relatives and five members of staff. The care of three people was examined and some aspects of care provision were observed. Feedback on our findings was given to the deputy manager. We would like to thank all the people living at the home, visitors and staff who helped with this inspection. What the service does well: What has improved since the last inspection? Changes have been made to the internal lay out of the building. The service is now geared mostly for people who experience dementia. All the bedrooms are now for single occupancy. The main doors have been fitted with a security alarm system for the benefit of people who live at the home. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 6 Some bedrooms and parts of the communal and service areas have been improved. What they could do better: Although the Statement of Purpose and Service User Guide had been reviewed, these documents need further improvement. They need to give more information about the service that is provided for people with dementia and other information as contained in the relevant guidance and regulations. The care planning system must be reviewed to make sure that individual care plans are based on identified needs and risks. Care plans must be properly implemented, with an appropriate record of care provided, and they must be evaluated and reviewed. The management and audit of medicines needs to be improved in order to safeguard the health and wellbeing of people who use the service. Management and staff should review and improve the provision of social and recreational activities with regards to the needs and capabilities of people who experience dementia. Staff should also demonstrate that they are able to assist people in their care to express preferences and make choices. These actions will help to improve their quality of life. Although the meals service was generally good, people should be given opportunities to make effective choices of beverages at mealtimes. The complaints procedure requires minor amendment to make sure it gives the appropriate information and encourages people to use it. The physical environment of the home should be further improved. There were issues relating to the heating, lighting of the premises, the inappropriate storage of various items and the quality of furniture, all of which may put people living at the home at some discomfort and risk. There is a need to improve the recruitment and selection procedures, in order to make sure that all pre-employment checks are appropriately sought and obtained before staff start working at the home. The manager needs to review the training needs of all care staff and take action to address any shortfalls, some of which are highlighted in this report. The manager should also make sure that a plan for the provision of staff supervision is developed and implemented. The registered persons should ensure that appropriate quality monitoring methods and quality assurance system are effectively used in order to improve the service. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 7 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.V355693.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 Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable to this service. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People who use the service had sufficient information to help them choose the home. However, there is a need to improve the information about its specialist services and its facilities, to make sure that people can make a more informed choice about their placement. Assessments of needs were carried out before people were admitted to the home in order to make sure that their care needs could be met. EVIDENCE: The Statement of Purpose and Service User Guide were available at the home, on request. Staff stated that copies of these documents were given to people who live at the home and their relatives. They were also given to people who Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 10 came to view the home for possible admission. Relatives told us that they were given sufficient information to help them choose the home. A copy of these documents was checked. They outlined the home’s philosophy of care well. However, they had some gaps in the information they provided. There was, for example, not enough information about the service that the home provides for people who experience dementia. This could result in people being less able to make an informed choice of the service. The care files of two people who had been admitted since the last inspection (July 2007) were checked. They showed that their needs had been assessed before their admission. However, in one instance, the assessment undertaken by the placing social worker had been sent to the home, only on the day the person was admitted. It was noted that staff at the home also carried out an assessment of needs in order to make sure that the identified needs of people could be met. Brookwood Residential Home DS0000065011.V355693.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 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living at the home were satisfied with the care they were receiving, which they felt was ensuring their security and wellbeing. The planning, provision and review of care was not always satisfactory and this could affect the quality of care provided to people using the service. EVIDENCE: The care plans of three people, who experience dementia, were checked. The care plans were generic in nature and were preset with twelve activities of daily living with similar sections to deal with any required interventions. They did not always include all the assessed needs of people using the service. One person, whose overriding need was assessed as requiring specific social Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 12 stimulation, had no discernible action plan to address it, except a note to say that staff should offer wide range of activities. Our case tracking of care provided to this person showed that more could have been done to address this need. The care plans we examined were not always well developed and implemented. Actions to meet identified needs were not always relevant and clear. The care plan of one person confirmed that there was no issue with continence, but an intervention to offer continence wear was nevertheless made. The record of care showed that continence wear had indeed been used at night, in line with the care plan. We noted that most of the people using the service were unable to take part in their care planning due to their condition. The care plans that we checked, showed no involvement from relatives or advocates. It was therefore difficult to establish the abilities and interests of people using the service and how staff could meet their needs and preferences. We found that the care needs of people were often documented together with the risks that they faced in their daily activities. However, risks were not always clearly identified and actions to manage those risks were unclear. In one instance, a risk assessment had shown that a person using the service could develop a pressure sore. The category of this risk was recorded but there was no record of action to be taken to manage this risk. However, staff we spoke to, were able to provide care and support to this person. The care provided was often recorded in a generalised way and therefore lacked relevant information. This led to inadequate evaluation and review of care. Reviews of care plans were undertaken but it was not clear what information had been used to justify the outcomes, which were mostly, that ‘no change was necessary’. We noted that in one instance a person, who had been in the home for a few years, had not had a recent review of his changing needs. There was therefore little guidance to care staff in their tasks of providing care to that person, particularly, with regards to his potential social problem of withdrawal and exclusion. The care plans that we checked indicated that people using the service were supported in accessing community health care services. The district nursing service and the community psychiatric team was involved in the health care of a few people. Care records showed that the services of the local GPs were appropriately accessed. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 13 Medicines received at the home were not always appropriately recorded and therefore could not be accounted for. In one instance, we found that one person had missed four doses of an item of medicine. Staff said that they had been contacting the GP for advice, on the administration of this medicine. One person had refused the use of a topical cream for some time, but there was no evidence that staff had referred this matter to the GP for a review. We noted that medicine trolleys and other care documentation were stored in two cupboards, located in communal space provided for people living at the home. The use of these cupboards, especially at meal times, seemed to interfere with the dining function. We noted that furniture was fairly close to the cupboards, especially when the doors were opened. This could affect the communal space available to people who live at the home. We spoke to three relatives who were visiting their loved ones. They said that, in their opinion, the care provided was fairly good and that staff were friendly and helpful. Brookwood Residential Home DS0000065011.V355693.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 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. People living at the home were able to benefit from some of the recreational activities that were available to them. This helped them in maintaining their quality of life. EVIDENCE: People living at the home were observed spending time sitting in the lounges and in their bedrooms, in between meals and care interventions. The television sets in two lounges were playing in the background. In one small lounge, there was a radio cassette, which played music. Two people were observed to be listening to the music. They said that they found the music to be ‘nice’. In the afternoon, staff were seen sitting in one of the lounges; talking and observing people. We spoke to staff and they said that there was a list of activities that they could organise for people living at the home. One member of staff was observed organising a game of bingo for about six people. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 15 The social care needs assessment for people using the service was often contained in a section of their individual care plan called ‘socialising’. It referred for example to activities like, chatting, board games and family visits. However, the care records of a person stated that he did not like to take part in any recreational activities, but in discussion we found that he had a keen interest in football. He would spend time watching football matches on his television. Staff were aware of his preferences but had not pro-actively catered for them. We spoke to three relatives who were visiting their loved ones. They said that they were always welcomed at the home. They commented that for most of the time, their loved ones could not express their preferences concerning their care or about things that they liked to do. They were confident that staff did their best to help people in their care. People using the service and their relatives said that the meals served at the home were usually good and tasty. We observed lunch being served. The menu for the day comprised of steak pie, fish and chips, and vegetables. Staff explained that they had assisted people using the service to choose their meals. However, we noted that staff gave every person an orange drink at lunchtime, without ascertaining their choice. In discussion, staff stated that they knew the likes and dislikes of the people in their care. They stated that every one liked the orange drink. Two members of staff were observed to be assisting people with eating their meals in order to make sure their nutritional needs were met. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 16 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 who use the service experience good quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. Relatives of people living at the home were satisfied that they could express their concerns to staff and that these would be addressed. Although there was an adult safeguarding procedure in place, all staff need to be trained in implementing it, in order to protect the safety and welfare of people using the service. EVIDENCE: There was a complaint procedure in place and it gave brief information on how to make a complaint and who would deal with it. The procedure was included in the statement of purpose. However, the procedure made a distinction between informal and formal complaints. These types of complaints were not explained and therefore were unclear. A few relatives commented that they were aware that a complaints procedure was in place and they would use it if necessary. They said that they usually talked to staff if they had any concerns and these would be dealt with in an appropriate manner. Staff stated that there had been no complaints in the last twelve months. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 17 There was also an adult safeguarding policy in place to promote the safety and welfare of people using the service. Staff were aware of this policy. Training records showed that most of staff had received training on the ‘Protection of Vulnerable Adults’. We spoke to care staff about adult safeguarding procedures and they were aware of them. We noted that two members of staff were yet to receive training on this subject. There had been no concerns about the safety of people living at the home in the last twelve months. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 18 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 who use the service experience adequate quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. The environment was not well maintained and health and safety issues were not always appropriately addressed. These shortfalls made the environment a less comfortable and pleasant place for people who live at the home. EVIDENCE: On the day of this inspection, there were two workmen carrying out some repairs inside the home. They were replacing the carpet in the office and relaying the one in the main lounge and repairing part of an upstairs corridor. No arrangements had been made before and during the work about protecting the health and safety of people who live at the home. Furniture and tools were Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 19 left on corridors and these presented a potential hazard. The matter was discussed with the person in charge and addressed in order to ensure the safety of people living at the home. We noted that some changes had been made to the building in order to cater for the needs of people who experience dementia. The main doors had been provided with keypads to ensure the security of people living at the home. All the bedrooms were for single occupancy. The communal areas were on the ground floor and consisted of two lounges, two dining rooms, a small quiet room and a small conservatory. A few pictures and notices were seen on the walls as signage for the lounges and toilets. We checked the premises and also viewed a few bedrooms with the permission of people who lived in them and their relatives. We found that the small conservatory had no heating in it, except a portable heater, which was placed near the doorway. Staff explained that the wall mounted electric heater had broken down and that the portable heater was the only source of heat. No risk assessment had been put in place for the use of this equipment. The light bulbs in some areas near the toilets, which were frequently used by people, were found switched off most of the time. Staff explained that some of the people who live in the adjoining rooms chose to switch those lights from time to time. One toilet near the quiet lounge was found to contain a number of disused furniture items and equipment stored in it. The door to this toilet was not locked and people could access it and thus face a potential safety hazard. Boxes of continence wear were found stocked in several bedrooms and they caused unnecessary clutter. We also found that a whole glazed door had been stored at the end of a corridor. One person said that it had been there for some time. We noted that one room was not provided with a staff call bell. The person occupying this room had apparently pulled out the ‘buzzer’ some time ago. She was therefore unable to call for assistance as necessary. We found that some of the furniture provided by the home to be very basic. Wardrobes had no backs and some were very loose. Some beds were not provided with headboards. Staff explained that these rooms were not currently occupied and that they were ready for new furniture and decoration. The bedrooms we looked at were adequately decorated and clean. A couple of bedrooms had persistent malodour in them, although staff had left the Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 20 windows open for a long time. The deputy manager explained that regular cleaning of these bedrooms was carried out to remove the malodours. The communal areas appeared clean and tidy. We noted a lack of ‘coffee’ and side tables for people to use. At coffee time, we noted that some people had to hold hot drinks on their laps or keep them on the floor. This practice was unsafe and undignified. The small kitchen, which is located next to a dining room, was found cluttered. It had a small ‘medicine fridge’ in it. We noted that there were no domestic staff in the afternoon and that any cleaning that was required, would be carried out by members of the care team. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 21 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 who use the service experience adequate quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. Although the care staffing level was adequate, its deployment did not always ensure consistency of care to people who use the service. This could affect the overall quality of care being provided. Staff recruitment and selection procedures and staff training were not sufficiently robust to promote the safety and wellbeing of people living at the home. EVIDENCE: At the time of this inspection, there were 23 people in occupancy at the home, twenty of whom had from dementia. The care staff on duty comprised of the deputy manager and four care workers. The support staff included the cook and a domestic, both working only part of the day. We noted that a few people stayed in their own rooms on the ground and top floors. Most people were observed spending the day in the lounges on the ground floor. We checked the duty rota and it showed that besides a senior carer, four care workers were regularly scheduled to work during the day and three at night. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 22 Staff said that they felt there was always sufficient staff on duty to allow them to provide personal care and one to one attention, to people using the service. However, during our visit, we noted that staff interaction with people who experience dementia was limited and rather inconsistent. Staff were observed undertaking a series of tasks, some of which were non-care duties like cleaning. On occasions, one member of staff would stay in one of the lounges to ‘keep an eye’ on people who were spending their time there. Two visiting relatives told us that they found the staff to be ‘nice and friendly’ and this gave them confidence about the way their loved ones were being cared for. Three new care workers had been recruited since the last inspection. We looked at the procedures that were used in their recruitment. We found that interviews were often carried out by only one person. Gaps in employment history were not checked and explained. In two instances, the required preemployment checks, including the appropriate disclosures and work references, had not been sought and obtained before staff started working at the home. The welfare and safety of people who use the service were therefore put at risk. We spoke to care workers about the training they had received in order to equip them with the required skills and knowledge to provide care, especially to people who experience dementia. A few carers confirmed that they had received training on a number of topics, including dementia care, moving and handling, infection control, food hygiene and adult safeguarding issues. However, two care workers said that they had not yet received any training on dementia care and on basic fire safety. They also stated that they had not yet undertaken training for their “National Vocational Qualification” in care. The manager had stated, in the ‘Annual Quality Assurance Assessment’ document, which was submitted before this inspection, that staff had received training on the “Mental Capacity Act 2005”. However, care workers we spoke to, had not yet received this training. They, therefore, lacked guidance on how to work with people whose capacity to make particular decisions may be uncertain or questionable. We noted that no training had been provided to staff on issues of equality and diversity. The care staff team itself, did not represent the cross-section of people who use the service. There was no male carer in the team. This may affect the way care is provided to people who use the service. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 23 Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using available evidence, including a visit to the service. Adequate management arrangements were in place to ensure the proper dayto- day running of the home. However, there were shortfalls in the management of health and safety issues and this could put people at risk. EVIDENCE: The registered manager has experience of working in residential care for older adults. She holds a “ Registered Manager Award”. In discussion, staff stated that they were satisfied with the way the manager was running the home. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 25 They felt that they were working well as one team and were able to provide as good a service as possible. We spoke to a few relatives and they told us that they were generally satisfied with the care that staff were providing to their loved ones. We looked at quality assurance methods that were being used to collect feedback from people who use the service and their representatives and to evaluate and improve service provision. The deputy manager explained that quality satisfaction questionnaires had been sent out at the beginning of January 2008, to the relatives of people living at the home and were expected back next month. There was no information relating to the outcomes of the previous quality satisfaction survey that was carried out. She commented that the manager would usually carry out audits of medicines and care plans. However, there was no evidence of the outcomes of such audits. We noted that the ‘Annual Quality Assurance Assessment’ document submitted to us, lacked evidential information and clarity about action being undertaken by the management on various issues. Staff told us that there were regular ‘Residents’ meetings and staff meetings. No further information about these meetings was available at the time of this inspection. We looked for copies of the provider’s monthly reports following his visits to the service and these were not available. Copies of the November and December 2007 visits were faxed to us. They contained insufficient information and indicated that management issues and progress were not effectively followed through. Arrangements were in place to support people living at the home with the management of their personal allowances. All financial transactions undertaken on behalf of the people concerned were appropriately recorded, witnessed and signed for and receipts were kept. These procedures ensured that their financial interest was being safeguarded. Accounts checked were in balance. We noted that a sum of money was made available for people who may need their money outside office hours. Some of the care workers stated that they had received only about three supervision sessions from the manager and other senior care staff. They were uncertain of the number and frequency of these supervision sessions. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 26 Information regarding the maintenance of equipment and the major utilities in use at the home was provided in the ‘Annual Quality Assurance Assessment’. Health and safety issues were discussed with the deputy manager and a sample of records was checked. Fire detection and fighting equipment had been appropriately maintained. No certificate of ‘thorough examination’ of the passenger lift was available for inspection. A copy of this certificate was sent to us afterwards. We highlighted our concerns about the inappropriate storage of several items and about the quality of some furniture, which constituted potential health and safety hazards. We drew attention to the lack of safety precautions shown before repair and refurbishment works were started. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? None 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 OP7 Regulation 15 Requirement Individual care plans must be improved to ensure they are appropriately developed, implemented and the care provided properly recorded, evaluated and reviewed. Risks that people face must be appropriately assessed and managed. This will ensure that all identified care needs are addressed. All medicines received at the home must be appropriately recorded so that they can be accounted for. Medicines must be administered as prescribed and where there is noncompliance, advice must be sought from the prescriber. This is to protect the health of people living at the home. The items stored in the toilet as identified, must be removed so that the toilet can be restored to its intended use. Appropriate and sufficient furniture and equipment, including call bells, must be provided in both the communal DS0000065011.V355693.R01.S.doc Timescale for action 09/05/08 2 OP9 13 09/05/08 3. OP19 23 09/05/08 4. OP19 23 09/05/08 Brookwood Residential Home Version 5.2 Page 29 5. OP29 19 6. OP30 18 and private areas used by people who live at the home, to ensure their comfort and safety. The recruitment and selection procedures must be improved to 09/05/08 make sure that the required preemployment checks are appropriately undertaken and in order to protect people who use the service from potential harm. All care staff who, work with 09/05/08 people with dementia must be appropriately trained to do so. The registered person must review the training needs of all care staff and plan any required training within an agreed timescale. This will improve the safeguarding and protection of people who use the service. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide should be reviewed to include all the required information, particularly with regards to dementia care, so that people can make an informed choice about the home Staff should make sure that they assist people living at the home to make personal choices and to express their views, whenever possible in order to improve the way that their social care needs are catered for. This will help to further improve their quality of life. People who use the service should be given more opportunities to choose what they want to drink at mealtimes. This will help to ensure that their dietary needs and preferences are more effectively met. The complaints procedure should be reviewed to clarify the types of complaints that the service will look at and how they will be managed. Heating and lighting should be improved in the home in order to ensure the comfort and wellbeing of people who live and work in it. The storage of boxes of continence products and other items, including equipment in various areas used by people living at the home, should be discontinued, in order to respect their private space. The use of the cupboards to store medicines and other items should be reviewed for the benefit of people living at the home and who suffer from dementia. All parts of the home should be kept clean, hygienic and free from malodours at all times, to ensure the dignity and comfort of people who live at the home. Efforts should be made to ensure that the care team reflects the diversity of people who use the service. The outcomes of internal audits and quality assurance systems should be used to continually improve the overall quality of the service. DS0000065011.V355693.R01.S.doc Version 5.2 Page 31 2. OP12 2 OP15 3. 4. 5. OP16 OP19 OP19 6. 7. 8. 9. OP19 OP26 OP27 OP33 Brookwood Residential Home 10. OP36 A plan for regular supervision of staff should be developed and implemented to enable staff to receive the necessary guidance and support in their care practices. Brookwood Residential Home DS0000065011.V355693.R01.S.doc Version 5.2 Page 32 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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