Inspection on 30/01/06 for Brookwood EMI Home

This inspection was carried out on 30th January 2006.

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 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 23/01/08

Brookwood EMI Home 18/07/07

Brookwood EMI Home 18/07/06

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Snydale Care Home

Hawkhills

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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 OPT Lead Inspector Ramchand Samachetty Unannounced Inspection 30th January 2006 11:30 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.V273305.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Brookwood Residential Home Address 12 - 14 Greenfield Lane Balby Doncaster South Yorkshire DN4 OPT 01302 310295 01302 853518 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 Doreen Robson 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.V273305.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18 May 2005. Brief Description of the Service: Brookwood is a residential care home for up to 30 residents in the category of older people. There are 16 places for older people assessed as being ‘elderly mentally infirm’ (EMI) and 14 places for older people who require residential care. Brookwood is situated in the Balby area of Doncaster. It is close to local shops, a church, a library and other local facilities. The building comprises of two adjoining Victorian semi-detached houses that are linked at both the first and ground levels. The side that is used for residents who are elderly mentally infirm, has a passenger lift to assist with access between the floors. The ‘EMI’ section is separated from the residential side by electro-magnetically operated locks on doors at both ground and first floors. There are 24 single and three double bedrooms as well as two dining and two lounge areas and a quiet room. There are garden areas to the front and rear of the Home, including an enclosed garden area for residents who are ‘elderly mentally infirm’. The Home is owned by Atheray Organisation Limited and is currently managed on a day-to-day basis by Mrs. Doreen Robson. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 30 January 2006, starting at 11.30 hours and finished at 15.30 hours. The inspection included a tour of the premises, conversations with a few residents and relatives and staff. The inspector also spoke to a visiting health care professional. Care documentation and other records were checked. The inspection focussed on the key standards that were not assessed at the previous inspection and a review of action taken by the Home to meet the requirements and recommendations that arose from the previous inspection. What the service does well: What has improved since the last inspection? Care planning and the recording of care provided to residents have improved. Social and leisure activities which residents undertake are also recorded. The Home’ s statement of purpose and service user guide, have been amended to reflect the recent change of ownership. They have been improved in line with the guidelines and are accessible to residents and their representatives as necessary. The physical environment of the Home is being gradually improved. New carpets have been fitted in some areas. A dining room and a lounge have been decorated. Some new chairs have been provided. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 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. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. The Home is providing adequate information about its services to prospective and existing service users. This allows for interested parties to make their choice of a care home and to monitor how well the service is meeting its stated aims and objectives. The care needs of residents are appropriately assessed on admission to ensure that identified needs can be met. EVIDENCE: The statement of purpose and service user guide have been reviewed to reflect the recent change of ownership of the Home. These documents were available at the Home and all residents had a copy in their rooms. The assessment of needs of a resident that was recently admitted to the Home was checked. The assessment carried out by the staff at the Home, was satisfactory. It addressed all the areas of known needs, risks and preferences of the individual concerned. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. Care planning is adequately meeting the assessed needs of residents. The health care needs of individual residents are appropriately met. The Home’s procedures for safe administration of medicines are not consistently being observed and this can put residents at risks. Action is needed to improve the administration and audit of medicines at the Home. EVIDENCE: A sample of care plans was checked. Both the documentation and content of care plans have improved. Care plans set out clear information on how individual residents’ needs should be met. Risk assessments were in place, as necessary. Entries about the care provided is detailed and linked to the care plan. Care plans were appropriately reviewed. Care records of residents showed that they were appropriately referred to a range of health care professionals, as and when needed. District nurses were attending to a small number of residents at the Home. One visiting health care professional commented that care staff was working well with the community health services for the benefit of the residents. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 10 The receipt and storage of medicines were found to be satisfactory. However, the handling and administration of medicines were not appropriately undertaken. Medicines administration records, (MAR) which were checked, showed a few discrepancies, which were unsafe and could put residents at risk. One prescribed item of topical application had been changed without authorisation, and a different one applied. On one occasion, an item of prescribed of medicines was not administered because ‘there were none in the medicine trolley’. Recording codes were not used in a consistent fashion. There were comments like ‘ fast asleep’ written on the MAR sheet, and no action was subsequently taken to assess the timing of this particular item of medication. The Home had the services of its dispensing chemist to audit its medicines. There was no internal audit system. It is recommended that the registered manager set up her own audit of medicines management at the Home. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15. Residents receive a nutritious and varied diet, which appear to meet their individual preferences and health requirements. EVIDENCE: In discussion with staff, it was noted that the food menus had improved. There was a good choice of food at each mealtime. Most residents are unable to make active choice on their own. Staff were observed to be helping residents who had difficulty expressing their food preferences, to make their choice. Two residents chose to partake their meals in their own bedrooms and they were assisted to do so. Lunch, on the day of this inspection, consisted of corned beef pie or lamb chops, with vegetables. There were rice pudding and chocolate sauce and fruits for desert. Residents, who spoke to the inspector, stated that they were satisfied with the meal s served at the Home. The meals served in the afternoon have also been improved. On the afternoon of this inspection, residents were served grilled sausages, baked beans sandwiches, salads and scones and fruits. Meals were accompanied with fruit drinks and tea. Staff have started to assess the nutritional needs of residents, in particular those who have specific dietary requirements, like diabetic diets. However, the floor of the dining room, on the residential side, appear to be deteriorating. It was not levelled in some areas. This dining area also a Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 12 photocopier and a pay phone mounted on two small tables. The location of this equipment should be reviewed. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were assessed at the previous inspection. EVIDENCE: Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19. The home is adequately maintained but requires some refurbishment to bring it to good standard. EVIDENCE: The inspector, accompanied by a member of staff, undertook a tour of parts of the building. The communal areas and some residents’ private rooms, which were viewed, (the latter with residents’ permission) appeared to be in good decorative state. However, some areas of floor coverings appeared stained and worn out. They need replacing. The floor in one of the dining rooms was not levelled in one area and poses a tripping hazard. A wall mounted electric heater in one of the conservatory was blowing very hot air on the residents who chose to sit there. They commented that it was too hot at times. The position and heat setting of this heater need to be adjusted. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 15 Storage of equipment continues to be problematic. In one of the residents’ bedrooms, there was a spare headboard kept near a cupboard. Staff stated that it was to be removed the same day. A refurbishment programme was not available at this inspection. The registered provider must develop such a programme with agreed priorities and appropriate timescales. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30. The staffing level was adequate and sufficiently skilled to meet the needs of the resident group. Care staff are being provided with adequate training to enable them to discharge their duties. EVIDENCE: At the time of this inspection, there was twenty residents in occupancy at the Home, eleven of whom were elderly mentally infirm and were accommodated in the EMI section. Besides the registered manager, there were four care workers, two of whom were senior carers. The support staff included a domestic, a handyman and a cook. Care staff were observed to be spending time with some residents, on a oneto-one basis. Relatives, who spoke to the inspector, stated that they were satisfied with the care that staff were providing to their loved ones. One relative said ‘ the staff take good care of my mother. They look after her well.’ Staff spoken to, confirmed that there was an ongoing training programme and that they had received training on a number of topics. These included courses on adult protection, medicines administration, moving and handling, first aid, Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 17 and health and safety and fire safety. It is commendable that 27 out of 28 care staff are currently qualified to NVQ level 2 in Direct Care. The deputy manager is currently undertaking training towards NVQ level 4 in Care and Management. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 35. The Home is being properly managed and staff are appropriately guided in order that they can provide a good quality of care to the resident group. There are adequate systems in place to safeguard the financial interests of individual residents. EVIDENCE: Relatives and staff, who spoke to the inspector, stated that they were satisfied with the running of the Home. One health professional, who was attending to a resident health care needs, commented that care staff were working well with her to ensure that the resident ‘s needs were appropriately met. In discussion, the registered manager stated that she has sent satisfaction survey questionnaires out to relatives and was awaiting their replies. The manager had organised ‘cheese and wine ‘ evenings for relatives and that has helped to get feedback on issues to do with care provision at the Home. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 19 The Home was managing the personal allowances of 15 residents. Three residents have their own bank accounts. One residents’ money is being managed by his legal representative. One resident personal allowance is being managed by her relative. Records regarding residents’ personal allowances were checked and found to be satisfactory. The accounts checked showed that income and expenditure were appropriately accounted for, and that they had correct balances. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 12, 13 Requirement Timescale for action 20/04/06 2 3 4 OP15 OP19 OP19 5 OP19 All medicines must be administered to residents, as prescribed. Any change or alteration must be authorised, recorded and signed for. 13, 23 The floor in the identified dining room must be repaired or renewed and made safe. 13,23 Areas of floor covering identified as stained and worn out must be replaced. 13, 23 The position and heat setting of the wall heater in the conservatory must be adjusted to ensure the comfort of residents. 12, 13, 23 The registered provider must develop a refurbishment programme, with appropriate timescale, for the Home. 28/04/06 05/05/06 20/04/06 20/04/06 Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP15 Good Practice Recommendations The registered manager should set up her own audit of medicines management at the Home. The location of equipment and the pay phone in the dining area should be reviewed. Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 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 Brookwood Residential Home DS0000065011.V273305.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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