Inspection on 29/11/05 for Brownrigg

This inspection was carried out on 29th November 2005.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brownrigg 10/12/08

Brownrigg 30/05/06

Brownrigg 10/05/05

Brownrigg 11/08/04

Brownrigg 23/04/04

Brownrigg 25/07/02

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Southfields

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

CARE HOME ADULTS 18-65 Brownrigg Borers Arms Road Copthorne West Sussex RH10 3LH Lead Inspector Jo Hartley Unannounced Inspection 29th November 2005 01:00 Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 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 Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 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 Adults 18-65. 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. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brownrigg Address Borers Arms Road Copthorne West Sussex RH10 3LH 01342 716946 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) Alliance Home Care (Learning Disabilities) Limited Mrs Penelope Ann Jenkins Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 6 persons in the registration category LD (learning disabilities) category aged 18-65 years who may also have a past or present mental disorder. 10th May 2005 Date of last inspection Brief Description of the Service: Brownrigg is registered with the Commission for Social Care Inspection to provide personal care for up to six people who have learning disabilities. (Category LD). The establishment is a detached two storey building set in its own grounds in Copthorne, West Sussex and is close to local shops, churches and transport. There are electric entrance gates installed at the entrance of the property. The service is privately owned by Alliance Homecare (Learning Disability) Limited. The responsible individual on behalf of the company is Mr A Dahya. The registered manager is Mrs Penelope Jenkins. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out over a period of three and a half hours. The inspector examined information held on the service file since the last inspection in May 2005, and read the previous two inspection reports, the Service User Guide and the Statement of Purpose During the inspection the inspector spoke to all the service users, and two members of staff. The inspector undertook a tour of the premises and looked at three care plans and three staff files. Various record books, policies and procedures were also examined. This report should be read in conjunction with the report of the announced inspection held on 10th May 2005. All the key standards, which should be inspected in a twelve-month period, are covered in these two reports. What the service does well: What has improved since the last inspection? A window restrictor has been fitted to the large window on the landing as required during the last inspection. Staff files now include two written references and proof of identification. The hall, lounge and stairway have been re-carpeted and some areas of the home have been re-decorated. Since the last inspection Mrs Penelope Jenkins has registered with the CSCI, and has been accepted as registered manager of Brownrigg. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 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. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The home has a statement of purpose and service users guide which provides the information service users need to make an informed choice about where to live. Standards Two, Three and Four were inspected during the last inspection and were found to have been met. EVIDENCE: The service users guide and statement of purpose seen prior to the inspection were found to be up to date, and to contain all the required information. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 The assessed and changing needs and personal goals of service users are reflected in their individual care plans. Standards Seven, Eight and Nine were inspected at the last inspection. Standard Seven was found to have been met. Standards Eight and Nine were found to have been exceeded. EVIDENCE: Three individual care plans were inspected and found to contain detailed information about service users’ needs and how they will be met by the home. Any specialist requirements are recorded in the care plan with details of how they will be met. Healthcare needs are clearly recorded. Any restrictions on choice or freedom are clearly recorded, including the reasons for the restrictions being in place. Evidence was seen that reviews are held at six monthly intervals, or more regularly if there is a change in circumstances or needs. All service users have an allocated keyworker. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of the above standards were inspected during the last inspection and were found to have been met. Standards Twelve and Thirteen were exceeded. EVIDENCE: Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 Service users receive personal support in the way they prefer and are able to make choices about their lives. Service users’ physical and mental health needs are met by the home and community health services. Standard Twenty was inspected during the last inspection and was found to have been met. EVIDENCE: Staff were witnessed providing appropriate support to service users during the inspection. Service users said that they choose when they go to bed and when they get up in the morning unless they are attending college or other appointments, when they have to get up in time to be ready to go out. Service users said they choose which clothes they wear each day. Consistency and continuity of support is ensured through allocated keyworkers and care plans that set out likes, dislikes and routines of individual service users. Individual records seen during the inspection show that service users receive additional specialist support and advice as needed from health professionals Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 12 outside of the home. A record is kept of every service users’ health appointments, the outcomes of the appointments and any action that needs to be taken. Staff said that they arrange any necessary appointments for service users and support them in attending. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home has a clear and effective complaints procedure that is understood by service users. Service users feel their views are listened to and acted on. It is recommended that the complaints log be amended to include dates and timescales of action. Standard Twenty-Three was inspected during the last inspection and was found to have been met. EVIDENCE: The home’s complaints procedure was seen and found to be adequate and to include the relevant timescales for action. The complaints log was also seen. One complaint had been made since the last inspection. It was not clear from the record whether or not the complaint had been dealt with within the required timescales. It is recommended that the log be amended to include dates and timescales of action. Service users said that they understand how to make a complaint if they have one. They said they would talk to the manager, their key-worker or raise problems in the house meetings that are held regularly. They felt that any worries or concerns they have are taken seriously by the home and are addressed quickly. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Brownrigg offers a homely, comfortable environment, which is well decorated and furnished. Service users’ bedrooms are comfortable and personalised. The home is clean, hygienic and free from unpleasant odours. The garden is well maintained and attractive. The large window on the first floor has been fitted with a window restrictor since the last inspection. Standards Twenty-Five, Twenty–Six and Thirty were inspected during the last inspection and were found to have been met. EVIDENCE: The home was found to be suitable for its stated purpose, accessible, safe and well maintained throughout. Evidence was seen that the fire alarm system and emergency lighting were last serviced and checked in November 2005. Fire extinguishers were tested in September 2005 and electrical appliances were tested in May 2005. A Legionella test was done in September 2005. Hot water temperatures are restricted. Records of regular temperature checks were seen and found to be within required safety limits. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 15 During the tour of the home it was noted that all radiators have covers. Windows in all the first floor rooms have window restrictors. A requirement was made at the last inspection for a window restrictor to be fitted to a large window on the first floor landing. This work has been completed within the required timescale. The home was seen to be well decorated, clean and tidy. Service users’ bedrooms were in very good decorative order and personalised to their own taste. Furnishings and fittings were seen to be of good quality. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Service users are well supported, and a competent, well-trained staff team meets their individual needs. The home has a recruitment policy that includes POVA checks for staff employed since July 2004. The home has a satisfactory recruitment procedure, however one staff record did not include a satisfactory employment history. A requirement has been made that a full employment history is obtained for prospective employees, and that any gaps in the employment record are explored prior to employment commencing. EVIDENCE: Records of staff training and qualifications seen during the inspection indicate that service users are supported by competent and qualified staff. The home has a comprehensive training programme available to staff which includes courses specific to the needs of service users within the home. Training that staff have undertaken includes Health and Safety courses, Medication, Epilepsy, Adult Protection, Sexuality Awareness and Equal Opportunities, among others. Evidence was seen that all new staff receive an induction programme within six weeks of employment and a foundation training within six months. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 17 Staff were seen interacting with service users, using appropriate communication, and listening to what was being said to them by individual service users. Three staff files were looked at, including that of the most recent staff member to be employed. It was found that the file for the most recently recruited staff member did not contain a full employment history, and there was no evidence that gaps in the employment history had been explored with the staff member prior to employment. The other files inspected contained all the required information. The manager needs to ensure that a full employment history is obtained for prospective employees, and that any gaps in the employment record are explored prior to employment commencing. A requirement was made at the last inspection that all staff files kept in the home include copies of two written references and proof of identification. This has been actioned within the required timescale. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 Service users benefit from a home that is well run by a qualified and competent manager. The health, safety and welfare of service users are promoted and protected by the home’s working practices and procedures. Standard Thirty-Nine was inspected during the last inspection and was found to have been met. EVIDENCE: The registered manager has the relevant qualifications and experience required for her post and to meet the home’s stated purpose, aims and objectives. Training records seen show that the home provides compulsory training for staff in safe working practices, including moving and handling, First Aid, Fire Safety, Food Hygiene and Infection Control. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 19 Evidence was seen that safety checks of electrical equipment, fire alarm systems and water temperatures are carried out on a regular basis. (See Standard Twenty-Four). The gas boiler was last serviced in June 2005. During the tour of the home it was noted that all radiators have covers, and windows in all the first floor rooms have window restrictors. Brownrigg DS0000014411.V260793.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Brownrigg Score 3 3 X x Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000014411.V260793.R01.S.doc Version 5.0 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation 19 Requirement Ensure that a full employment history is obtained for prospective employees, and that any gaps in the employment record are explored prior to employment commencing. Timescale for action 29/01/06 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 22 Good Practice Recommendations A record of dates and timescales to be included in the complaints record. 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