Inspection on 05/10/06 for Brownhill Lodge

This inspection was carried out on 5th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brownhill Lodge 24/04/07

Brownhill Lodge 14/02/06

Brownhill Lodge 11/08/05

Brownhill Lodge 21/09/04

Brownhill Lodge 10/12/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Brownhill Lodge 334 Brownhill Road Catford London SE6 1AY Lead Inspector Ornella Cavuoto Unannounced Inspection 10:00 5 &13 October 2006 th th 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 Brownhill Lodge DS0000025613.V314140.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. Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brownhill Lodge Address 334 Brownhill Road Catford London SE6 1AY 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) 0208 698 4978 tom_erman@hotmail.com DSRE Services Limited Lynda Anne Higgins Care Home 21 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (21), Physical disability (1) of places Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. This home is registered for 21 persons of whom up to 21 can be elderly 1 person, aged 55 years or above, suffering from a mental health disorder Up to 10 elderly persons can have dementia Up to 4 elderly persons can have a physical disability 1 person, aged 55 years or above, with a physical disability Date of last inspection 14th February 2006 Brief Description of the Service: Brownhill Lodge is a large detached house in Catford, South East London. There are good local public transport links. The home is situated on the South Circular Road. It is approximately 10 minutes walk from a parade of local shops and a short drive from Catford town centre, which has some larger shops. It is registered to provide 24-hour care for 21 older people 10 of whom can have dementia. The aim of the home is to provide high quality residential care and support services in a homely and caring environment in which residents can be persuaded and will be encouraged to determine the pattern of their lives. The home has one double bedroom that used to be shared by two service users but is now used as a single room and the remaining service users each have a single bedroom. The home consists of a ground floor and two other floors, which are now serviced by an accessible lift. There are no en-suite facilities but there are three bathrooms and seven toilets. One bathroom on the ground floor has been has converted to become a shower room that is accessible to wheelchair users. There are links with local health services for on-going advice and follow-up visits. Most referrals are drawn from social services department through the home finding scheme. The home employs a registered manager, sixteen care staff, one senior care staff, one full time cook and cleaner. Staff are experienced and are well trained. A newly appointed registered manager recently came into post in June 2006. There were four vacancies at the time the inspection was held. Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over a day and half. The registered manager, who has only been in post since June 2006, was not present for the first day of the inspection as they were on annual leave. However, the operational manager was able to attend the home and facilitated the inspection. The registered manager was available on the second day that the inspection was completed. Five service users and a relative were spoken to and also two care staff. Other methods used included inspection of care records and a full tour of the premises. What the service does well: Service users and relatives spoken to were happy and satisfied about the home and the service they were receiving from staff. One service user spoken to said, “ I’ve been here for 2 ½ years and this is a lovely home”. Also regarding staff the same service user said, “ They are very, very good, everyone of them from the top to the bottom. They can’t do enough for you”. Another service user said, “The food is nice, they look after you if you are not well. They see to you”. A relative commented, “ Both my sister and I are happy that she is safe here”. The home ensures they obtain a full needs assessment from referrers prior to admitting service users to ensure they are able to meet individual service users’ needs. Health care needs of service users living at the home are well met. Care staff treat service users respectfully ensuring their right to privacy is maintained at all times. Service users are consulted regularly about what types of different activities they would like to be involved in and opportunities are provided for them to engage in a range of different activities inside and outside the home. The home supports and encourages service users to maintain regular contact with friends and relatives and also to keep links with the local community. Where possible service users are encouraged to take control of their own lives and do things for themselves such as manage their own finances. Service users are also able to bring in their own personal possessions into the home when they move in. Generally the meals provided at the home are nutritious with a choice offered although the suppers need to be a little more varied. Service users are protected by the home’s effective complaints procedure and adult protection policy and procedure. All staff have been trained around adult abuse and action to take if abuse is suspected or identified. Care staff working at the home receive regular training and 50 of care staff have achieved a NVQ Level 2 in care to ensure the needs of service users are met effectively. Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 6 The views and feedback of service users are regularly sought through resident meetings and customer satisfaction surveys to ensure the home is run in their best interests. 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. Brownhill Lodge DS0000025613.V314140.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 Brownhill Lodge DS0000025613.V314140.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 &4 Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has updated the statement of purpose and service user guide to ensure that prospective and current service users have the information they need about services offered by the home. The home has drawn up a statement of terms and conditions but this is still to be issued to service users. Service users have had their needs assessed prior to admission. The home is able to meet the needs of service users moving into the home. EVIDENCE: At the last inspection it was reported that the statement of purpose was in the process of being reviewed and was not available for inspection. The service user guide was looked at and was found not to include all the information required by regulation. At this inspection updated copies of the statement of purpose and service user guide were inspected and found to meet with National Minimum Standards (NMS) and regulation although a new regulation now specifies that all homes must specify fees payable and a breakdown of the Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 9 fees must also be provided within the statement of purpose. This came into effect from September 1st 2006 and therefore needs to be added to the home’s statement of purpose. This will be checked at the next inspection. In addition, the service user guide was yet to be issued to service users but the registered manager reported that a copy would be kept in each service users’ room. This will be also checked at the next inspection. At the last inspection the statement of terms and conditions was in the process of being revised. At this inspection the updated copy of the document was seen and was found to meet with regulation although it was still to be issued to service users and to be signed (See Requirements). The personal files of four service users were looked at. Two of these belonged to service users who had been admitted to the home since the last inspection and one had moved in very recently. Both included evidence that full needs assessments had been obtained prior to their admission to ensure the home was able to meet their needs and that these had been used as a basis to draw up their individual care plans. There was evidence that staff individually and collectively do have the skills and experience to deliver the services and care which the home offers to provide and that overall the home does have the capacity to meet the assessed needs of service users admitted to the home. Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 10 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): 7,8,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service There has been a significant improvement in the details contained within individual care plans but care plans for all service users are still to be completed and they need to be reviewed on a regular basis. Service users’ health care needs are fully met. The home has robust medication policies and procedures but not all care staff working at the home are implementing these consistently. Service users feel they are treated respectfully and their right to privacy is upheld by the home. EVIDENCE: The home uses the Standex format for care plans. At the last inspection it was reported by the registered manager working at the home at that time that care staff were having problems with using Standex and that training was required to help them understand how to use it more effectively. The training was organised shortly after the inspection took place. Care plans inspected had some information contained in the ‘long term assessment’ for the majority of service users but detailed care plans outlining action to be taken by staff to Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 11 meet individual service users’ needs had not been completed for any of the service users. At this inspection the new registered manager reported that the care plans did not adequately address service users’ needs at the time they started working at the home in June 2006 and it had taken time to ensure that the care plans meet with National Minimum Standards (NMS) and that this is still a work in progress. Four service user care plans were looked at. Overall, there had been a marked improvement in the details contained in the care plans with service users, personal, health care and social care needs being addressed although for one service user parts of the care plan had not been completed. There were risk assessments in place for all service users that paid particular attention to falls and measures to reduce risks were specified. However, the service user, a family member or a representative had not signed one of the care plans. The care plans also had not been regularly reviewed and so did not always reflect the changing needs of service users, for example daily recording for one service user noted that blood tests had identified that the service user was anaemic but this had yet to be included in the care plan to ensure this would be addressed and monitored (See Requirements). There was evidence within service users’ care plans that their individual health care needs are fully met by the home. The home has recently introduced tools to assess and monitor service users’ nutritional needs and risks around pressure area care and these areas have also been addressed within care plans. Monthly weight monitoring had been recorded. In addition, a range of different health professionals who have visited individual service users was also noted within service users’ care plans including a GP, chiropodists, opticians, podiatrists, district nurses and dentists. A physiotherapist visited the home whilst the inspection took place to support a service user with doing exercises. Subject to a previous requirement the room temperature where medication is stored and also the fridge temperature for the cold storage of medication have both been checked daily and recorded to ensure both remain at recommended levels. However, a previous requirement that staff should ensure that medication administered to service users is accurately logged on Medication Administration Record (MAR) sheets and where medication cannot be administered to service users appropriate codes are used, this remains unmet. A sample of MAR sheets was inspected and it was identified that for two service users medication had been given that had not been signed for on occasions. Also, for one service user a code was entered on the MAR sheet that stated that it was ‘not required’ but the medication was not prescribed to be given ‘as and when required’ and no further explanation was written as to why this had not been administered at the back of the MAR sheet as would be expected in these circumstances. Furthermore, stocks of tablets were found not to correspond with quantities specified on MAR sheets or with the drug inventory sheets used by staff daily to record medication not placed in blister packs that had been administered and the number of tablets remaining. For Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 12 some of the medication it was difficult to check stocks of tablets, as the quantity including any balance brought forward from the previous month had not been entered on the MAR sheets as required. Finally, it was noted for one service that they were being administered medication that had not been written on the MAR sheet (See Requirements). Service users spoken to confirmed that staff treat them respectfully and that their right to privacy is upheld with staff always knocking before entering their rooms. Where it has been assessed as appropriate service users have been issued with a key to their room this was also confirmed by service users spoken to. Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 13 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): 12,13,14 &15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A range of activities is provided to service users both inside and outside the home. The home supports service users to maintain contact with family and friends. Service users are supported to exercise control and choice in their lives where possible. Generally service users are provided wholesome and nutritious meals although the suppertime could be more varied. EVIDENCE: There was evidence within individual care plans of service users’ social care needs being addressed. There was also an activities log in place that listed a range of different activities including card games, throwing the ball Halloween activities, painting, knitting, outside entertainment amongst others and a list of service users names of those that had participated. On both days that the inspection was held bingo was played with prizes given out for those that won. Also, during the inspection music was played and a sing-a-long took place on one of the days. There was evidence of the arts and crafts that the service users had completed for Halloween. The registered manager reported that they are still in the process of developing activities for service users. There is not a Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 14 set weekly programme in place instead the registered manager asks the service users every month what they would be interested in doing. Activities were also discussed as part of resident meetings that were held. In terms of outside the home the registered manager reported that a group of service users had been taken to the Pump House museum in the summer, which they enjoyed. Some had also been to the local theatre to see a musical and some went to a barbecue held at another home situated locally. One of the service users spoken to confirmed this whilst another service user described the different activities they had been involved in, “ I do painting, they play bingo sometimes, we often have a sing-a-long, parties now and again and a singer comes in.” Although, it was evident that the social care needs of service users are being met it is advised that more is done in respect to reminiscence, as this would be particularly important for those service users with memory impairment/dementia. The registered manager reported that some of the staff have received training around reminiscence. It was also reported that the aim is to bring someone from outside to do sensory work with service users. A further recommendation is that the home’s key worker system is used to spend individual time with service users particularly those that may not engage with the group activities and this should also be recorded (See Recommendations). Service users spoken to confirmed that they have regular visits from family and friends and there was evidence within daily recording that one service user stays with their son on occasions at weekends. A priest from the local church visits the home. It was reported that none of the service users have requested to see a representative from the Church of England. As mentioned service users have been taken out on outings within the local area. Also, one of the service users attends a day centre locally that meets their specific cultural needs. Where appropriate service users are encouraged to take control of their own finances with two service users managing their personal allowance/money. Service users are also allowed to bring in their personal belongings when they move into the home and service users’ rooms inspected were found to be suitably personalised. The home has information available for service users on where they can access advocacy if required. The home had a four- week rolling menu in place but it was noted that this was not always kept to. However, meals provided to service users were recorded in a diary and it was evident that a choice of food was offered. On the day of the inspection the cook went around all the service users informing them of the choice of meals for lunch and asking them want they would like. Service users spoken to were happy with the food. One service user said, “The cook is very good. They come round and if you don’t like the food they will give you something else. If they have got it you’ll have it” The lunch- time was Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 15 observed and the food provided was nutritious and the portions were ample. The lunch -time was generally relaxed and unhurried although a member of the care staff was assisting a service user to eat standing up. The services manager addressed this with the staff member who went to get a chair but all care staff need to be made aware that this is inappropriate practice (See Requirements). In terms of the food provided at supper times the menu was not very varied. It included a lot of sandwiches and in looking through the diary it was noted that service users had been given egg on toast twice in three days. The cook reported that the staff are responsible for providing the suppers although food is sometimes prepared beforehand such as homemade soups and cakes, jacket potatoes. There was some evidence in the diary to confirm this but it is recommended that ways of trying to make the suppers more varied are looked into further (See Recommendations). Brownhill Lodge DS0000025613.V314140.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service The home has a robust complaints policy and complaints are thoroughly investigated. Service users are protected from abuse. EVIDENCE: Subject to a previous requirement the complaints policy of the home has been altered to include addresses and contact telephone numbers of various places where service users can access independent advice or representation. Service users spoken to did not have any complaints about the home but were clear that they would bring their concerns to the registered manager or the operational manager. It was noted within the resident meetings held that service users were encouraged to raise any concerns or complaints. The home’s complaint log was inspected and there had been one complaint since the last inspection. This was from ambulance staff about the conduct of the carer who was accompanying a service user to hospital. This had been thoroughly investigated and appropriately addressed. The complaint was partially substantiated. At the last inspection the home’s adult protection policy was inspected and was found not to be very comprehensive. However, the home had a copy of Lewisham’s Adult Protection Policy and Procedure, which is a very detailed document for staffs’ reference. At this inspection, it was found that the home Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 17 had added information to its adult protection policy and procedure and was now robust in its content. All permanent care staff working at the home have completed training in adult abuse and staff files that were looked at included evidence of this. Two staff spoken to both had good working knowledge of different types of abuse and action to take if abuse of a service user was suspected or identified. Brownhill Lodge DS0000025613.V314140.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24 &26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service The home is generally well maintained although urgent repairs were required to the conservatory which was providing a health and safety risk to service users. The home has sufficient toilets and washing facilities and the shower room on the ground floor has now been completed. Service users’ rooms were suitably personalised and the home was generally clean and hygienic although two service users’ bedrooms need to have the flooring changed due to unpleasant smells. EVIDENCE: The home is generally well maintained. It is suitable for its stated purpose and is bright and airy. All parts of the home are accessible to service users with a passenger lift being in situ and the home can accommodate wheelchair users. Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 19 The home has adequate communal space with a separate dining area, a lounge and conservatory area that leads out to an attractive garden. However, it was noted that towels were laid out in two separate areas of the conservatory. It was reported that as a result of building works being carried out on the property next door to the home the roof of the conservatory had been damaged causing water leakage when it rained. The builders had admitted liability and the home was waiting for a date for the repairs to be carried out. However, concerns were raised as the extent of the leak was seen as it began raining at the time the inspection was in process. As a result of the health and safety risk to service users an immediate requirement was issued that interim measures must be taken by the home to stop the water coming into the conservatory and that repairs to the roof should be carried out by the end of the month. The home has since sent evidence to the Commission of Social Care Inspection (CSCI) that this has been completed. This meets the immediate requirement issued. The home has sufficient bathrooms and toilets some of which the home are in the process of decorating. In one toilet on the ground floor, the toilet seat was seen to be broken. This needs to be replaced as it could potentially cause an injury to service users. Since the inspection was held evidence has been sent to indicate this has been completed. However, this will still need to be checked at the next inspection (See Requirements). Subject to a previous requirement that the home needed to redo the work on the shower room on the ground floor to make it accessible for service users particularly to those who are wheelchair users and have mobility problems, this has been met. The work has been completed to a high standard and one service user who is a wheelchair user stated, “The new shower is brilliant for me.” Service users’ bedrooms were inspected and were all found to be suitably personalised with all required items of furniture. However, the carpets in two service users’ bedrooms were quite badly stained and there was a notable smell of urine in both rooms. Therefore, the home needs to look into replacing the flooring for these two service users. Since the inspection was held evidence has been sent to indicate this has been completed. However, this will still need to be checked at the next inspection (See Requirements). Apart from the two individual bedrooms the home was clean and hygienic on the days the inspection was held with no other offensive odours present. Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 20 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): 27,28,29 &30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service There were sufficient staff working at the home to meet the needs of service users. The home has met the required target that 50 of care staff should have achieved a National Vocational Qualification (NVQ) in care Level 2. The home’s recruitment practices protect service users. Regular training is offered to staff ensuring they are competent and able to meet the needs of service users but future training needs have to be planned for. EVIDENCE: It was observed on the day of the inspection that there were sufficient levels of staff on duty. The home has three care staff on duty in the morning and afternoon and where service users require an escort to attend an appointment an extra staff member is placed on the rota. Three care staff are on duty in the afternoon and evening and two care staff do a waking night. The registered manager reported that nine of the twelve permanent care staff working at the home have completed a NVQ Level 2 in care with four care staff having just recently finished and are waiting for their certificates. Consequently, the home has met the required target specified within the National Minimum Standards (NMS) that 50 of care staff need to have obtained a NVQ Level 2 in care. In addition, one staff member has a NVQ Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 21 level 3 and two care staff have qualifications at a higher level of the NVQ with one being a qualified nurse although they obtained their qualification abroad. Six staff files were inspected and all were found to include the necessary checks and information required by regulation. Five staff had an Enhanced Criminal Record Bureau (ERCB) check in place. One staff member who had recently started working at the home a new ECRB had yet to be obtained although an application form had been completed and there was evidence that a check against the POVA list that includes the names of staff that are unsuitable to work with vulnerable adults had been carried out. There was evidence that all the other information required by regulation such as two references and appropriate identification had also been obtained for all the staff whose files were looked at. Staff files looked at included evidence that the majority have completed mandatory training including manual handling, food hygiene, fire safety, health and safety, safe handling of medication as well as some specific training in areas including introduction to dementia, challenging behaviour, introduction to diabetes. Annual appraisals had been completed with staff but the home had yet to draw up an annual training plan to identify future mandatory and specific training needs for staff (See Requirements). The home uses a comprehensive induction booklet drawn up by Mulberry House that covers all aspects of care and practice within the home and appears to meet with skills for care specifications. This had been completed for all staff except one. The manager was still in the process of going through the booklet with them. Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 22 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): 31,33,35 &38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service A person who is experienced and qualified to ensure the home is well run manages the home. The home is generally run in the best interests of service users although monthly provider reports have not been sent consistently to CSCI. Service users finances are safe guarded by the home. Overall, the home ensures the health, safety and welfare of service users are protected although not all necessary checks on fire equipment have been carried out. EVIDENCE: Since the last inspection a new manager has started working at the home having begun in June 2006. They have been registered by CSCI and are experienced having worked in a nursing home previously for older people with Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 23 dementia. They also have relevant qualifications having achieved both the NVQ Level 2 and 3 in care and are a NVQ assessor. They are currently undertaking the NVQ Level 4 in management. In terms of quality assurance the home completed customer satisfaction surveys last year in November 2005 with service users, relatives and professionals involved in working with the home. The results in terms of responses received were seen which were low. It was reported due to the poor response the results were not published in a report or feedback given. However, it is recommended whatever the response feedback should still be offered even if it is just to inform that the number of surveys returned was poor. The home were in the process of carrying out another survey this year and evidence was seen of those surveys to be issued to service users and relatives which were both comprehensive in the areas covered. The home was also to hold a stakeholders meeting as part of the survey. In addition, the home holds regular resident meetings. The minutes of the meetings were seen and a range of issues was discussed with service users including obtaining their views and feedback on outings/activities and food. As mentioned in respect to standard 16 service users were also encouraged to raise any concerns or complaints they had about the home at meetings. The operational manager reported that they have completed monthly provider reports. However, copies of these reports have not been sent to CSCI and this needs to be addressed (See Requirements). The home manages the personal allowance for the majority of the service users living at the home although as mentioned two service users do take control of their own finances. The home has robust procedures for looking after service users’ monies and receipts are kept for all expenditure. The home has comprehensive health and safety policies and procedures in place. A sample of maintenance certificates were checked which were all found to be up to date, for example, electrical wiring was done October 2005, Portable Appliance Testing January 2006, gas boiler and system May 2006, fire alarm, emergency lighting and call buzzers in service users’ rooms were checked September 2006 and had been done quarterly. The home has an up to date fire risk assessment in place and health and safety checks on the building are completed monthly. The home has carried out regular fire drills but checks on fire alarm call points had not been completed weekly as required (See Requirements). Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 24 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 2 3 3 X X 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 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 (1) (b) Requirement Timescale for action 31/03/07 2. OP7 15(1)&(2) (c)&(d) 3. OP9 13 (2) The registered person must ensure that all service users are issued with a contract outlining the terms and conditions of their stay within the home, which they sign and a copy kept on their individual files. (Previous timescale of 31/05/06 partially met) The registered person must 31/03/07 ensure that all service users have a completed care plan in place that outlines their individual needs. Also, that the care plan is signed by the service user, their relative or a representative where appropriate to indicate their involvement in the care planning process and that care plans are reviewed monthly to reflect any changing needs. (This is an updated requirement. Previous timescale of 31/05/06 partially met) The registered person must 31/03/07 ensure that the systems in place for the administration and recording of medication are used DS0000025613.V314140.R01.S.doc Version 5.2 Brownhill Lodge Page 26 4. OP9 13 (2) 5. OP9 13 (2) 6. OP15 12 (1) 7. OP20 23(2) (b) 8. 9. OP21 OP24 23(2)(b) 16(2)(k) consistently, specifically that all staff ensure they sign the medication administration record sheets for medication that is given to service users and appropriate codes are entered when medication cannot be given to service users. (Previous timescale of 31/05/06 not met) The registered person must ensure that the quantity/stock of tablets including any balance brought forward is written on the Medication Administration Record (MAR) sheets at the beginning of each monthly cycle. The registered person must ensure all medication that is prescribed and administered must be written on the MAR sheets. The registered person must ensure that all care staff are aware of the correct practice and procedure for assisting a service user to eat and that these are adhered to at all times. The registered person must ensure that temporary work on the conservatory is carried out to prevent water leaking through and that the necessary repairs are carried out by the end of October 2006. (Immediate Requirement issued 05/10/06. Evidence sent to CSCI that work has been carried out on the conservatory was received 31/10/06). The registered person must ensure that the toilet seat identified as broken is replaced. The registered person must ensure that the carpets in the two service users’ bedrooms that were identified as stained and DS0000025613.V314140.R01.S.doc 31/03/07 31/03/07 31/03/07 31/10/06 31/03/07 31/03/07 Brownhill Lodge Version 5.2 Page 27 10. OP30 18 (1)(c) 11. OP33 26(5) 12. OP38 23(4)(c)(i v) leaving an offensive odour in the rooms are both replaced. The registered person must ensure that an annual training plan that sets out all specific and mandatory training is drawn up. The registered provider must ensure that copies of the monthly provider reports are sent to CSCI. The registered person must ensure that fire alarm call points are tested weekly and this is recorded. 31/03/07 31/03/07 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP12 Good Practice Recommendations The registered person should consider implementing more activities that involve reminiscence for those service users experiencing memory impairment /dementia. The registered person should consider using the home’s key worker system to ensure that individual time is spent with service users particularly those that may find it more difficult to engage in group activities and a record of this is maintained. The registered person should still consider offering feedback on customer satisfaction surveys where a low response had been received. 3. OP33 Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Brownhill Lodge DS0000025613.V314140.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!