Inspection on 27/02/07 for Brymore House

This inspection was carried out on 27th February 2007.

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

Brymore House 06/02/06

Brymore House 27/09/05

Brymore House 31/03/05

Brymore House 28/10/04

Brymore House 14/01/04

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 Brymore House Brymore House Residential And Nursing Home 243 Baring Road Lee London SE12 0BE Lead Inspector Sue Meaker 27 & 28 th th Unannounced Inspection February 2007 10:00 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 Brymore House DS0000007010.V300562.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. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brymore House Address Brymore House Residential And Nursing Home 243 Baring Road Lee London SE12 0BE 020 8851 4592 020 8851 4207 brymorehouse@hotmail.com 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) Mr Michael Marjoram Mrs Mary Marjoram Mrs Sharon Feleppa Care Home 46 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0), of places Terminally ill (0) Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 30 patients elderly, frail persons aged 60 years and above (female) and 65 years and above (male) 20 residents persons aged 55 years and above, and persons suffering from dementia 14 of the beds registered as `nursing` can be used for either patients or residents - maximum of 46 patients and residents combined to include one person with palliative care needs Up to 11 patients, aged 60 or above if female or 65 and above if male, for intermediate care using bedrooms 2, 3, 4, 5, 7, 27, 28, 29, 30 and 31. 6th February 2006 Date of last inspection Brief Description of the Service: Brymore House is located on a main residential road and is about 5 minutes walk from Grove Park railway station and the local shops. The house is a large detached property with its own drive. There is an attractive enclosed garden and patio at the rear of the house. The accommodation is on three floors; the rooms in the home vary in shape, as part of the house was originally a private residence which has been extended, however the room sizes meet regulations, rooms are accessed by stairs and a shaft lift provides level access to all parts of the home. The registration is for a maximum of 46 service users, up to 30 of who may require nursing care. There is also one place for palliative care and eleven places for intermediate care. The building works have now been completed, the new intermediate care facilities are now fully functioning and office space has been designated for the social worker, occupational therapist and physiotherapist for the intermediate care unit; this unit now has eleven en suite rooms and also has its own kitchen, bathroom and gym. The registered providers have recently appointed an intermediate care specialist nurse to be specifically responsible for the unit. The manager is a Registered General Nurse, and has attained the Registered Managers Award she also has considerable years of experience in nursing and management. The home now has a new kitchen and adjoining dining room; the communal lounge is now more spacious, there is a new office for the home manager and a Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 5 new kitchenette facility for visitors. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a statutory, unannounced key inspection that took place over two days. Discussions were held with the registered manager, the home administrator, the registered nurses and staff on duty in the home over the two days including the activities co-ordinator, the housekeeper, chef, the receptionist and the hairdresser. A number of residents and their relatives were spoken to over the two days and a number of completed questionnaires were received from residents and relatives. The registered manger completed a pre-inspection questionnaire that was returned to the CSCI prior to the inspection. Eight residents’ care plans and assessment documentation was viewed as well as nine personnel files. Documentation relating to health and safety, training, activities, quality assurance, medication, finance and policies and procedures were viewed at the Inspection. A tour of the home was also undertaken and the completed building works were viewed particularly the new en suite rooms, facilities and offices in the intermediate care unit, conversation were also held with the social worker, physiotherapist and occupational therapist responsible for this unit within the home. This was a satisfactory inspection and there were positive comments from the residents and relatives; the staff were also very positive about the home and it was evident that there was a good rapport between the residents and relatives and the management and staff of the home. The home had addressed the requirements and recommendations made in the last report many had been implemented with a few requiring further implementation. What the service does well: The home has a stable staff team many of whom have worked at the home for many years and are very experienced and qualified ensuring that the residents assessed personal, health and social care needs are well met. Residents and their relatives were very positive in their comments about the home:• There is a stable and caring staff team, and a super matron. • There is a friendly and welcoming atmosphere – everyone comments on it. • The catering is excellent. • They have a good blend of youth and experience. • They treat everyone equally. • They are always friendly and happy with the residents. • Treat all the residents with care and respect. • Brymore cannot improve it does a great job as it is. • We hear from the media and television about things that happen in nursing homes, I think it is time to let people know about the good one’s Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 7 • • because they deserve some good press, they do a fantastic job not because they have to but because they care. The staff stop and chat and joke with the residents. The leisure co-ordinator seems particularly competent with plenty of new ideas. The home has an effective intermediate care service with good facilities to ensure that service users can be supported around improving their mobility and activities of daily living to enable them to work towards being successfully returned to live at home. The service also has good links with specialised staff such as a physiotherapist, occupational therapist, consultant doctor and social worker. Over 50 of the care staff have achieved a National Vocational Qualification (NVQ) Level 2 in care and staff are given regular opportunities to attend training courses in respect to mandatory training and more specific training to meet the individual needs of service users. What has improved since the last inspection? The home has reviewed and updated the homes’ Statement of Purpose and Service User Guide. Residents have a copy of the guide in their rooms and are able to request a copy of the Statement of Purpose. The home has made sure all residents have a contract outlining the terms and conditions of their stay within the home. Residents and their relatives receive a copy to sign and a copy is kept on their personal files. The home ensures that the residents in the intermediate care unit, who are aiming to return home, have the ability to self- administer medication this issue is looked as part of their care plan and risk assessment and that those service users that can administer their own medication are encouraged to so. All residents and their relatives are sensitively and compassionately consulted around their personal wishes for death and dying and this information is recorded as part of their care plans. The home ensures that the residents are consulted about their individual leisure interests, and that all care staff are involved in undertaking activities with the residents The home has reviewed and revised their Access to Information policy to include reference to the Data Protection Act 1998. The home has arrangements in place to inform service users, their relatives and representatives of how to access external advocacy services. The home’s complaints policy has been revised to ensure that timescales are included for the investigation of complaints and for residents, relatives and Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 8 representatives are to be informed of the outcome. All residents have been issued with a copy of updated policy. The home ensures that when recruiting staff that all the required documents are in place prior to staff members being allowed to start working within the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 9 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 Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential residents are able to access the information they need to make an informed choice about where to live. Residents receive a written contract stating the statement of terms and conditions of the service and accommodation offered by the home. All service users have their personal, health and social care needs assessed prior to moving into the home. From documentary information and from being able to visit the home, residents, relatives and friends know the home will meet their individual needs. Service users and their relatives and friends are encouraged to visit the home to enable them to assess whether the home is able to meet their assessed personal, health and social care needs. Residents in intermediate care are helped to maximise their independence and return home. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 11 EVIDENCE: The Statement of Purpose and Service User Guide were inspected. Since the last inspection both documents have been reviewed and updated and now complies with schedule 1 regulation 4 (1) (c). Service users and relatives contacted said that they received enough information about the home to help them make a decision; one person said that the home was “good with information and another said that they were advised to visit the CSCI website to get further information and that she also visited the home prior to admission and each time was told that she could visit at any time. It was noted that all residents rooms viewed (with their permission) had a copy of the homes’ service user guide in their rooms, Residents receive a written contract outlining terms and conditions of their stay with the home. Self- funding service users automatically received a contract but those funded by social services also receive a contract from the home, evidence of contracts being issued was found in the resident’s personal files. Contracts viewed specified terms and conditions of the services provided and detailed the residents accommodation; the contracts seen, included all the information specified in the standard; were signed by the residents and relatives. Eight residents files were inspected and all had either a social services assessment or an assessment from the hospital; the registered manager stated that all residents have an assessment carried out by a trained nurse prior to being admitted to the home; risk assessments are also done at this time; this enables the resident and their relatives to feel confident that the home is able to meet their personal, health and social care needs. Residents contacted said that they felt the care home met their care needs and that the service provided supports them to live the life they choose. One relative said, “I feel her needs are catered for”. During a discussion with the home manager it was decided that a document be developed to summarise the hospital and social services assessment to make it easier to formulate an individual care plan. The majority of staff at the home have worked there for many years and individually and collectively are both experienced and qualified. Residents and relatives contacted confirmed that the management and staff of the home have the right skills and experience to look after people properly one relative said that they” treat all the residents with care and respect individually” and another said “they treat him as a person in his own right”. There was also evidence, in the eight personnel files inspected, that staff have received training to ensure that the specific needs of residents are met including palliative care training, dementia and challenging behaviour and intermediate care training. Therefore, residents and their relatives are able to feel confident their assessed personal, health and social care needs can be met. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 12 Since the last inspection the building work has been completed and the intermediate care unit now has eleven en suite rooms; with additional facilities such as a gym, a fully equipped bathroom with additional aids and a small kitchen for comprehensive recovery and therapeutic programmes to be undertaken with residents, including support with activities of daily living and mobility. The aim of the intermediate care unit is to enable patients to maintain themselves safely at home; this is done over a four week period and the home has a contract with the local PCT and Social Services; the home has recently recruited an intermediate care specialist nurse who will be supported by a team of designated care workers who have received rehabilitation support worker training; this training comprises of five training sessions incorporating the structure, teams and roles of workers in the unit, handling difficult situations, stroke patients, background, moving and handling and speech and language therapy; psychology, falls and anxiety and the causes and prevention of falls; community nursing and breathing difficulties COPD. There are good links with specialised staff, who are based at the home who include a physiotherapist, occupational therapist and social worker from Lewisham’s Intermediate Care (LINC) team and a consultant who regularly visits the home. The home is also working towards ensuring that an integrated approach is used between the LINC team and the home’s nursing and care staff to maximise the support received by intermediate care service users. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans set out in sufficient detail the residents personal and social care needs. Residents are enabled to make decisions about how their healthcare needs are met. Where appropriate, residents are encouraged to take responsibility for their own medication. Residents feel they are treated respectfully and their privacy maintained. The home consults sensitively with residents, family or friends around their personal wishes and instructions at the time of death. EVIDENCE: Eight residents’ care plans were inspected. A previous requirement that the care plans should set out in detail the personal and social care needs of residents has now been met. The care plans looked at included details of the specific needs of the residents and how they are to be met. The care plans Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 14 specified the way in which the residents’ wishes and preferences relating to personal care routines were to be met. The recording on the personal care daily evaluation was clear, concise and consistent. The care plans also had evidence of a dependency tool being used to assess the residents ability to manage certain tasks for themselves; primarily about how independent they are and how much assistance is required to maintain the activities of daily living. The care plans viewed included information relating to the social background of the resident, details of their hobbies and interests and a completed Life Review form which is aimed at developing a social care plan tailored to individual residents’ needs. In addition, care plans are evaluated on a monthly basis and signed and dated by the either the nurse or care worker; however there was no evidence of the care plans being signed by the resident or their relative; currently there is an ongoing audit of all care plans and a planned revision is being undertaken involving residents and their relatives. Residents and relatives spoken to during the inspection confirmed that they had been involved in the care planning process and they had input into how they would like themselves and/or their relative to be cared for; if they needed any aspect of their care to be changed this was done during the review and their care plan was updated accordingly. The care plans inspected confirmed that the residents health needs were met, the GP visits the home on a weekly basis and there is also an out of hours emergency service provided by the surgery. The residents also have access to a dentist, podiatrist and optician; specialist services are also provided by the GP’s surgery and these include the occupational therapist, physiotherapist, psycho-geriatrician, continence and tissue viability nurses and dietician. All visits by any healthcare professionals are documented in the care plan making sure that ongoing health needs are monitored regularly and preventative and restorative care is provided. The home has robust policies and procedures for dealing with the safe administration of medication and for the intermediate care residents who are enabled and encouraged to take their own medicines. It was evident from speaking to the nurses on duty and from observing the nurses giving medication at lunchtime; that the staff that give medication are trained to do so and that they are required to undertake specialised training in this area. The home manager is responsible for monitoring the medication processes as part of the homes’ quality assurance systems and evidence was seen to support that this monitoring was being carried out on a monthly basis. A number of MARS sheets were inspected and all displayed a photograph of the resident, and all were found to be accurate, the controlled drugs book was also inspected and found to comply with regulations. The medicines were stored securely and safely in a designated clinical room. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 15 In the previous report a recommendation was made relating to enabling residents to take their own medication if appropriate. Residents are supported and encouraged to take their own medication particularly in the cases of the intermediate care residents; assessments are undertaken prior to admission and the appropriate risk assessments are put in place and monitored carefully by the intermediate care team in the home. Residents have a lockable space in their rooms in which to store their medication and medication issued is accounted for and documented. It was evident from observing the interaction between staff and residents during the time spent in the home that the privacy and dignity of service users is maintained, it was noted that the staff sensitively and unobtrusively help their residents with tasks enabling them to achieve a level of independence within the home. One relative spoken to said that the staff treat all residents with care and respect, another said that they treat my husband as a person, and that they have a good and caring relationship with the people living here; ready to stop and talk and joke with them. Residents spoken to confirmed they are treated with courtesy and that there privacy and dignity is respected when the staff is helping them with their personal care needs. All residents spoken to and observed were well dressed and well groomed and all confirmed that they are able to choose their own clothes. During the inspection the hairdresser was in the home and the residents spoken to enjoyed having their hair done and looked forward to participating in this activity and said it gave them the opportunity to chat to other residents thereby making it a pleasant social experience; the hairdresser had been visiting the home on a regular basis for a number of years and it was evident that she knew the residents well and listened to how they wanted their hair styled and that she was sensitive to their individual wishes and preferences. Also, all bedrooms have a telephone line so that service users can have the use of their own telephone if they wish, enabling them to keep in touch with their families and friends. The eight care plans viewed had documentation relating to the residents’ wishes relating to death and dying; some of which had been completed; on speaking to the home manager she stated there was some resistance by families as to giving this specific information but she was looking towards speaking to residents and their families about this issue and hopefully be able to document their individual wishes and she and her staff would continue to sensitively consult with residents, family members and representatives where appropriate on this issue. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to participate in activities that match their personal preferences and interests. The home endeavours to encourage relatives and friends of residents to participate in activities within and outside the home enabling the residents to maintain their preferred lifestyle. Residents are able to access information relating to local advocacy services to ensure they can fully exercise choice and control over their lives. Residents are provided with a healthy, nutritious and balanced diet in congenial surroundings and at an appropriate time. EVIDENCE: The home’s activities co-ordinator continues to work on ensuring that residents are supported and encouraged to participate in the structured activites on offer in the home if they wish; one relative said that the “leisure co-ordinator seems particularly competent with plenty of new ideas” another said that the staff are “always friendly and happy with the residents, and have many small clubs and Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 17 things to do”. The residents are involved in-group activities during this inspection they were making greetings cards and there were also ball games taking place which the residents enjoyed, the activities co-ordinator and some of the staff were chatting to the residents on a one to one basis. The coordinator maintains a record, which was inspected of all the activities that are organised, who participated and a brief note on whether the activity was enjoyed or not. A note is also made of those service users with whom individual time is spent. The residents are offered a wide range of activities which include reminiscence, arts and crafts, knitting and crochet, bingo, board games and puzzles; residents are also able to watch DVD’s and videos on a recently purchased plasma screen television. Some of the staff team have undertaken training in hand massage and other complimentary therapies that the residents have enjoyed and have found soothing and comforting. Staff had also attended training on how to develop skills in reminiscence from the Pumphouse Educational Museum. In addition, various musicians and singers are brought into the home to entertain the residents on a regular basis. It was evident from talking to the residents that their relatives and friends are made to feel welcome in the home; during the inspection a number of relatives were visiting the home throughout the day they said that they felt comfortable, that the management and staff of the home were approachable and that they had no problem voicing concerns and that these concerns were resolved quickly and in a sensitive and compassionate manner. Residents also said that they felt that they were supported and encouraged to live the life they choose; one relative said that the staff “treat all the residents with care and respect their individuality” another said that “they treat everyone equally. Residents are supported and encouraged to exercise choice and control over their lives; the residents handle their own financial affairs as long as they wish to; the home administrator is able to help if the resident has no family if this is the case a receipt is issued to the resident for any monies spent and a copy of the receipt is kept by the home. Residents and their relatives are able to access external advocates who are able to act in their best interests the home details this information in the service user guide. From visiting the residents in their rooms, with their permission, it was evident that every effort is made to ensure that they are able to personalise and individualise their room with pictures, photographs, ornaments and small pieces of furniture; residents said that they were encouraged to bring in personal items that were important to them. It was evident from inspecting the personal records of the residents that the storage and access to these records complied with the Data Protection Act 1998 Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints policy and procedure is clear about the home’s responsibilities in investigating complaints, making sure that the process is transparent and completed within the set timescale. All staff working within the home have received training on adult protection procedures and abuse awareness ensuring that the residents feel safe and protected in their home environment. EVIDENCE: The home has a robust policy and procedure relating to complaints; this document is displayed in the foyer of the home and is detailed in the Statement of Purpose and in the Service User Guide; thereby making sure that residents and relatives have access and know how to express a concern or complaint. Service users and their relatives contacted confirmed that they were confident that the home would respond appropriately should they raise concerns about their care; one relative said “there have only been minor issues and have always been resolved quickly. The complaints policy and procedure was updated in December 2006 and includes the timescales for the investigation of complaint, details of the outcome of the investigation and the resolution of the complaint and when this information is to be communicated to the resident if appropriate and/or relatives. In the previous report a Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 19 requirement was made that the updated complaints policy needed to be included in the Service User Guide and this must be issued to all service users – this has now been done and each resident now has a copy of the Service User Guide in their room. The home has had three complaints, all of which were responded to within the 28 day timescale and from inspecting the complaints log a thorough investigation had been carried out all of which was documented and the outcomes communicated to the complainant; all complaints documented had been satisfactorily investigated and the complainants were satisfied with the outcome and subsequent resolution. It was evident from speaking to staff and from looking at the staff training records that the registered manager is making sure that the staff received specific training relating to the Protection of Vulnerable Adults. There are robust policies and procedures relating to this issue, the policy and procedure was updated in September 2006. The registered manager is able to provide in house training and uses a training video produced by the Department of Health and this is used to increase staff awareness around adult abuse and procedures to be followed. Since the last inspection the registered manager has arranged for staff to attend training courses, via the London Borough of Lewisham Training Consortium on adult abuse which the staff team have completed, staff also receive training on the Protection of Vulnerable Adults, the PVA register and Whistle-blowing during induction and as part of their NVQ qualification. The Registered Manager demonstrated her knowledge relating to referring allegations of abuse to Social Services Adult Protection and when a referral to the POVA register is appropriate; there have not been any instances of an investigation under POVA at the home to date. The registered manager has applied to the London Borough of Lewisham for a copy of their Adult Protection Procedure for information and unfortunately have still not received any copies for the staff team; the Registered manager has recently been in contact and is awaiting a response. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is clean, pleasant, hygienic, comfortable, safe and well maintained with access to safe and comfortable indoor and outdoor communal facilities. Residents have their own comfortable bedrooms specific to their needs and have easy access to suitable lavatories and washing facilities. Residents are provided with specialist equipment to maximise their independence EVIDENCE: Since the last inspection the building works have been completed; the intermediate care unit now has eleven en suite bedrooms, in addition to a gym, specially adapted bathrooms and kitchen the home also provides office space to the on site social worker, physiotherapist and occupational therapist. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 21 The new kitchen and dining areas are now fully operational, there is a new managers office and a kitchenette has been added for the use of visitors to the home. The building work has been finished, decorated and equipped to a good standard. The home has an ongoing redecoration and refurbishment programme in operation and the home also has a full time maintenance person who keeps the home in a good state of repair. The communal areas within the home are of a good size and decorated and furnished to a good standard, there are quiet areas where residents and their relatives were chatting, there was also activities taking place in other areas, some of the residents were making greeting cards and some residents were playing a ball game in a separate space; residents have access to a paved garden area with shrubs and flower beds. Many of the residents bedrooms are en-suite and are arranged on three floors, residents are also able to access separate toilets and bathrooms close to those rooms that do not have en suite facilities. Residents are able to access all parts of the home via a passenger lift and the home provides grab rails, hoists and assisted toilets and baths a enabling the home to meet the assessed needs of the residents. The home has a call bell system that is easily accessed by residents, relatives and staff in the event of an emergency. During a tour of the home with the registered manager a number of residents rooms were seen; the rooms were well decorated and furnished residents spoken to confirmed that they were able to bring their own personal items into the home and that they could choose how their room was decorated and furnished. Residents also had access to a lockable space in their rooms and were able to have a key to their room if they wished. It was evident from checking health and safety records and from observations during a tour of the premises, that the home meets the relevant environmental health and safety requirements in respect of heating, lighting, water supply and ventilation of the residents’ accommodation and also considers and meets the individual needs of the residents. The laundry was also inspected, the laundry person had a good knowledge of COSHH regulations; and confirmed that the domestic staff of the home had completed their NVQ in cleaning via Bromley College; and that they had all received specialist COSHH training. The laundry person also had a good knowledge of infection control and information relating to these issues was displayed in the laundry. The laundry was well equipped with three washing machines, three dryers, an ironing machine and a steam iron; all the equipment was in good working order and well maintained. The laundry seen was in plentiful supply and in good condition, the residents clothing seen was well cared for, labelled and in good repair. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff on duty with the required skills to meet the needs of service users. Over 50 of the care staff have obtained the National Vocational Qualification (NVQ) Level 2 in care. Residents can feel confident that the homes recruitment and selection policies and procedures ensuring that they are supported and protected. The staff of the home has access to training opportunities and a training plan is drawn up to ensure the training needs of staff are addressed. EVIDENCE: The home’s rota was examined which accurately reflected the numbers of staff on duty the two days the inspection was carried out. It was also evident through observation that there was more than sufficient staff available to meet the needs of service users. The home ensures that there three qualified nurses and nine care staff on duty on an early shift, two nurses and seven care staff on an afternoon/evening shift and one nurse and four care staff on at night. It was reported that to date 59 of the care staff have obtained a NVQ Level 2 in care meeting the target that at least 50 of staff should have obtained this Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 23 qualification or an equivalent by the end of 2005, a further 5 members of staff are currently undertaking NVQ 2. Nine staff personnel files were inspected and all were found to comply with schedule 2 (regulations 7, 9 and 19) 0f the National Minimum Standards –Care Homes Regulations – Care Standards Act 2000. There was a separate file containing evidence that CRB and POVA checks had been carried out and that the pin numbers of the nurses employed had been checked with the NMC; this information is recorded and the document files in compliance with the Data Protection Act 1998. The registered manager is currently undertaking an audit of all the personnel files and re-organising the information so it is easily accessible; a discussion took place at the feedback session and it was suggested that one file for each staff member should be used and there would be separate sections for application information, training, supervision and annual appraisal documentation, the registered manager stated that she would implement this suggestion. Staff files contained a copy of the terms and conditions of employment, signed copies of the homes’ policy and procedure relating to equal opportunities, confidentiality, death of a resident, a missing resident, what to do in the event of a fire and the acceptance of gratuities. Staff have access to all the homes; policies and procedures and the code of conduct and practice set by the GSCC. The nine personnel files inspected included individual certificated training undertaken by the staff in the home; the registered manager has accessed training from the London Borough of Lewisham Training Consortium and the Care Home Support Team; specific training relating to meeting the assessed needs of the intermediate care residents the care of the intermediate care residents. Staff spoken to confirmed that they had received induction training and the mandatory training in moving and handling, food hygiene, health and safety and fire training. Staff are also supported and encourages to undertake NVQ training and the home offers NVQ 1 in cleaning and NVQ 2 and 3 in social care; staff skills and competence is also enhanced by specialist training in intermediate care practice, dementia care, challenging behaviour, diabetes, palliative care, first aid, safe handling of medication, food and nutrition, POVA, care planning, infection control and wound care. Currently the registered manager does not have an annual training plan in place as she is awaiting information regarding courses to be offered from the homes’ training providers; this issue was discussed at the inspection and the registered manager will send the plan to the Commission as soon as it is available supplemented by a list of staff and the training they will complete in 2007. Residents contacted confirmed that the management and staff of the home have the right skills and experience to look after people properly and that they are able to meet the different needs of people; one relative said that the staff are a good blend of youth and experience and have always cared appropriately for their relative, and another said that there is a stable and caring staff team and an excellent matron in the home. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and managed by a competent and experienced person; benefiting from an effective and efficient management approach ensuring that the residents feel safe and protected at all times. The home is in the process of implementing an adequate and effective quality assurance system ensuring that the home is run in the best interests of the residents. The Registered manager is in the process of implementing a structured supervision and appraisal system for staff ensuring the personal development and training needs of all the staff are met. The home promotes and protects the health, safety and welfare of residents, relatives and staff. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager has been working at the home since 2001. She is a qualified nurse and has also completed the NVQ Level 4 in management and is a member of the Chartered Institute for Managers. She is very committed to training and regularly attends conferences and training days to update her knowledge and skills. It was clearly evident from observations between the manager staff and service users that they find her approachable and she is also very knowledgeable about staff and service users needs. A requirement was made in the previous report that an effective quality assurance system based on seeking the views of service users and reporting the findings back in a report which is then made available to service users, relatives, their representatives, other stake holders and also to CSCI is in the process of being implemented; a new questionnaire has now been developed. The registered provider and manager investigated the possibility of introducing an externally recognised professional quality assurance tool that has been developed by the National Care Homes Association. In respect to service users’ money it was reported that where possible the home encourages service users to manage their own finances or relatives to do this on their behalf. The home only has responsibility for managing one service user’s personal allowance as the service user does not have any next of kin. The administrator takes overall responsibility for managing the account that has been set up by the home and is non-interest bearing. A record of all financial transactions is kept on the home’s computer. Receipts are presently kept by the home and copies issued to the service user in respect to transactions that take place. A requirement in the previous report that staff must receive regular supervision and an annual appraisal has not yet been fully implemented, the systems are now in place and the registered manager is documenting evidence of supervision sessions on the individual staff members personnel file an annual appraisal system has also been implemented and this will ensure the future development and training needs of the staff member will be met. The registered manager has developed a new supervision form and staff now receive a supervision contract; staff confirmed that they had regular one to one meetings with their supervisor and that they attended regular staff meetings; they also stated that the management team of the home were approachable and felt they could confidently discuss any worries and concerns they had and be sure that they would be listened to and that the identified problems would be resolved satisfactorily. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 26 The home has robust health and safety policy and procedures in place that comply with current health and safety legislation. A health and safety risk assessment and hazard analysis had been completed and recently updated to incorporate the changes to the home after the completion of the building works. Maintenance certificates were seen including that of the home’s gas boiler, electrical equipment, passenger lift and hoist equipment. There was evidence that water temperatures are regularly checked to prevent against the risk of scalding and also tested for the risk of Legionella. A building and fire safety risk assessment are both in place. The kitchen had been inspected by the local authority’s environmental health inspector on the 12/02/2007 everything was in order no requirements or recommendations were made in respect of the new kitchen. The home has a comprehensive policy and procedure relating to fire safety which has been recently revised to include the new parts of the building; the registered manager stated that the fire alarm, emergency lighting, fire equipment was tested on a regular basis. However the recording of these checks were patchy, this issue was discussed with the registered manager who stated that she would check with the maintenance person to ensure that all the fire records are all up to date. The fire book was inspected and indicated that the times of the drills have not been consistently recorded to ensure they are carried out at different times to include night staff. A record of the testing of call points was not available, and there was no written record of PAT testing although the maintenance person has carried out these checks. It was reported that the maintenance man carries these out. Since the last inspection a fire safety inspection by the LFEPA has been carried out on the newly built intermediate care section of the home, and evidence of this has been received by the CSCI, as requested. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 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 3 2 X 3 2 X 2 Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 28 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 OP33 Regulation 24 Requirement Timescale for action 30/06/07 2. OP36 18 (2) 3. OP7 15(1)&(2) (c)&(d) The registered person must ensure that an effective quality assurance system based on seeking the views of and reporting back findings to service users, their families and other stakeholders is in operation at the home. (Previous timescale partially met) The registered person must 30/06/07 ensure that all staff receive regular individual supervision and that each session is formally recorded. (Previous timescale partially met). 30/06/07 The registered person must ensure that service user plans sets out in detail the action that needs to be taken by staff to ensure all aspects of personal and social care needs of service users are met. 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. (Previous timescale has been DS0000007010.V300562.R01.S.doc Version 5.2 Brymore House Page 29 4. OP7 15(1)(b) 5. OP30 18 (1) (c) 6. OP38 23 (4) (e) partially met) The registered person must 30/06/07 ensure that service user plans are reviewed on a monthly basis. (Previous timescale has been partially met) The registered person must 30/06/07 ensure that all staff receive an annual appraisal to identify individual training needs and that an annual training plan is drawn up, and submitted to the CSCI (Previous timescale has been partially met) The registered person must 30/06/07 ensure that -Regular fire drills are carried out at different times to ensure all staff are involved and these times are recorded. -Fire alarm tests recorded -Call bell checks recorded -Emergency lighting tests recorded. -PAT testing recorded -Fire equipment checks recorded. 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 3 Refer to Standard OP18 OP29 OP33 Good Practice Recommendations It is recommended that the Registered Manager of the home follows up the request for the Local Authority’s Adult Protection Policy and Procedure. It is recommended that the Registered Manager continues the audit and re-organisation of the staff personnel files. It is recommended that the registered manager continues to investigate the possibility of using an externally recognised professional quality assurance to use in DS0000007010.V300562.R01.S.doc Version 5.2 Page 30 Brymore House conjunction with the system already in place. Brymore House DS0000007010.V300562.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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